GW1-2022-08434_Well Construction - GW1_20220420

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14_WATER7.0NE3 : >"
Well Contractor Name FROM TO DESCRIPTION
4449-A 245 fL 285 fL 7GM
ft. fL
NC Well.Contractor Certification Number
15OUTER'CASING;for:mWti-ca§ehwells`OR_1.iNER"ifa cable
Rowan Well Drilling FROM I TO DI(METER THICKNEss 5ATMAL
0 fL 150 fL 6 A m SDR21 PVC
Company Name
317365 :46ANNERCASING'ORTUBING eotHermal lasedloii
2.Well Construction Permit#: FROM I TO I DIAMETER ITHIC� MATERIAL
Lhi all applicable well cotutruciton permits(i.e.1IIC,Comity,Stale,Parlance,etc) ft. ft. in.
3.Well Use(check well use): ft. % bu
Water Supply Well: 17:'SCREEN
FROM TOI WAMETER I SLOTSI2:E THICKNESS I 'MATERIAL
Agricultural [DMunicipal/Public ft. ft. to
Geothermal(HeatinglCooling Supply) EiResidential Water Supply(single) 1Y tr in
IndustriaUCommercial [311esidential Water Supply(shared) 18i-GROUT
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft. Holeplug Gravity 36 bags
Monitoring Recovery ft. ft.
Injection We1L ft. ft.
Aquifer Recharge [3Groundwater Remediation
�:19aSAND/GRAVEL PACK if a ''ible
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test �]Stormwater Drainage ft. fL
Experimental Technology Subsidence Control ft. ft.
'Geothermal(Closed Loop) 0TraCer 2Q DRILY 1NG:LOG'attach aildidonat sheettaf uecessa
Geothermal(Heating/Cooling Return) MOther(explain under#21 Remarks) FROM To I DFSCREMON cotor,barrraas soltimir bw,gmin sim.eta. ,
0 ft 20 fL clay
4.Date Well(s)Completed:3/8/22 Well ID#317365 20 ft. 100 ft. sandy overburden
5a.Well Location: rm fL 140 fL sandy overburden/weathered rock
Kelly McLain 140 fL 160 fL solid rock
FaciliVOwner Name Facility ID#(if applicable) 162 ft rM fL soft rock
3370 Mt Hope Church Rd, Salisbury 28147 ft. ft. j -�, i§Nm
Physical Address,City,and Zip ft. ft.
Rowan 418 158 ZI:REBIARKS".
County Parcel Identification No.(PIN) ~
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IatAong is sufficient) t'"%3^''A.''� 1
22.Certification: �;•:�;;,ur.�.�I'l;r,t rskJ
35 34 8.265 N 80 30 6.935 W
6.Is(are)the well(s)OX Permanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the i ell(s)ryas(mere)cans truded in accordance
7.is this a repair to an existing well: [3Yes or EX No with ISA NCAC 02C.0100 or 15A NCAC 02C.0200[Yell Construction Standards and that a
If this is a repair,fill out known ivell construction information and explain the nature of the copy of this record has been provided to.the it-ell auger.
repair tinder Ul remarks section or on the back of thisform.
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
9.Total well depth below land surface: 285 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths i#dii ferent(example-3@200'and 2 ter 100) construction to the following:
10.Static water level below top of casing: (fL) Division of Water Resources,Information Processing Unit,
Ifrvater 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) 7 Method of test:'airlift 24c.For Water Supply&Infection 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: 13 oz completion of well construction to the county heaith department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016