GW1-2022-08445_Well Construction - GW1_20220829

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14.WATER ZONES
Well Contractor Name FRONT TO DESCRIPTION
4449-A 280 ft- 300 ft• -0 GFh1
345 ft 375 fl, 1G GRA
NC Well Contractor Certification Number 15.OUTER CASIN for multi-cased wells f a li OR LINER icable
Rowan Well Drilling FROM TOG DIAMETER TDICKNESS NIATERL\L
Company Name 0 ft. 1 124 ft- 61/4 in. SDR21 PVC
326699 16.INNER CASING OR TUBING eothermat closed-loop)
2.Well Construction Permit#• FROM 'to DIAbIErER THICKNESS MATERIAL
List all applicable well construction pennils 0.e.UIC,County,State,irariance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE ITIIiCiL^IESS I MATERIAL
" Agricultural QMunicipal/Public ft. fL in.
Geothermal(HeatinglCooling Supply) OResidential Water Supply(single) ft. ft. in.
industrial/Commercial Residential.Water Supply(shared) 18.GROUT
Irrigation FROM TO _ MATERIAL EIIPLACENIENThfETHODA AMOUNT
Non-Water Supply Well: o ft. 21 ft. Holeplug Gravity 32 bags
Monitoring QRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge QGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
I- Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG'attach additional sheets ifnecessa
D Geothermal(Ffeating/Cooling Return) "`: Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiUrock type,grain size,cte.
0 ft. 15 ft. clay
4.Date Wells Completed:7/13/22 Well ID#326699 15 ft. 100 It.
()Com p sandy overburden
5a.Well Location: too ft. 114 ft. weathered rock
Adrian Barrera 114 ft. 124 ft. solid rock
Facility/Owner Name Facility IDff(if applicable) 129 ft. 134 ft. vein
173 Falcon Crest Lane, Salisbury 28147
Physical Address,City,and Zip
ft. ft.
Rowan 825033 21.REMARKS q
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/iong is sufficient) 22.Certification:
35 44 2.348 N 80 35 31. 332 W
6.1s(are)the well(s)oPermanent or OTemporary Signature ofCcrtified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordwice
7.Is this a repair to an existing well: Oyes or iX No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200{Yell Construction Standards and that a
If this is a repair fill out larown well.construction information and explain the nature of the copy of this reeonl has been provided to the x e//owner.
repair under 921 reinarks section or on the back of this fora).
23.Site diagram or additional well details:
S.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: 385 A) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depdts fdiJferent(example-3@200`and 2@1001 construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water 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 pusli,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) 25 Method of test: weir 24c.For Water Sum &In I fection 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: 18 oZ completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016