GW1-2022-08433_Well Construction - GW1_20220829

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
4449-A 210 ft. 226 ft. 2 GPM
390 ft. 405 ft. 3 GPM
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 IL 156 ft. 61/4 in. SDR21 PVC
Company Name
377�22 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. In.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) DResidentiai Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) t8,GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Holeplug Gravity 13
Monitoring QRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
_ 19.SAND/GRAVEL PACK if applicable)
:)Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test L'=.NStormwaterDrainage ft. ft.
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) [3Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soil/rock t e, rain sae,etc
HGeothermal(I Ieating/Cooling Return) Other(explain under#21 Remarks)
0 ft. 16 ft, red clay ,
4.Date Well(s)Completed: 7/18/2022 Well ID#377022 16 ft. 146 It.
sandyoverburden
Sa.Well Location: 146 ft. 156 ft* solid rode
Lourdes Ortiz 156 ft. 275 ft, brown rod<I soft
Facility/Owner Name Facility ID#(if applicable) ft. ft.
430 E Ridge Rd, Salisbury 28144 ft. ft. -� 1�z
4 5
Physical Address,City,and Zip ft. ft.
Rowan 31OB021 21.REMARKS
County Parcel Identification No.(PIN) `^--
rl is
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
35 43 19.183 N 80 29 30.501 W I
6.Is(are)the well(s)&Permanent or QlTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E)Yes or IX No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature ofthe copy of this record has been provided to the well owner.
repair under 921 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:' SUBMITTAL INSTRUCTIONS
405
9.Total well depth below land surface: (ft.) incompletionf well
P 24a. For All Wells: Submit this form with 30 days of o
For multiple wells list all depths if dierew(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
Rotary above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 5 Method of test: Weir 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Chlorine Amount: 19 oz completion of well construction'to the county health department of the county
where constructed.
I
Form GW-1 North Carolina Department of Environmental Quality-Division of water Resources Revised 2-22-2016