GW1-2022-09373_Well Construction - GW1_20221010

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4449-A 160 rt. �
ft. tt. i
NC Well Contractor Certification Number 1S.OUTER CASING for multi cased wells OR LINER if a'`Gcabte
Rowan Well Drilling FROM TO DIAMETER THICKNESS t1iATERIAL
Company Name
0 ft. 160 ft. 6114 in. SDR21 PVC
378625 16.INNER CASING OR TUBING tgeothermat closed=loo
2.Well Construction Permit#: FROM TO ItHkMETER THICKNESS I MATERIAL
Liss all applicable well construction permits(i.e.WC.C'ounuy,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 I THICKNESS MATERIAL
Agricultural OMunicipaUPublic ft, ft, in.
Geothermal(Heating/Cooling Supply) E)Residential Water Supply(single)
CL ft.
lndustrial/Commercial Residential Water Supply(shared) is.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft 21 ft. holeplug gravity 13
Monitoring _ Recovery ft. ft
Injection Well:
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK If applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft ft,
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.-DRILLIIVG LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardnm%soufrock type,grain sae,etc.
0 ft. 15 ft, red clay,
4.Date Wells Completed:8/5/22 Well ID#378625 15 ft. 90 ft
()Com p sandy overburden
Sa.Well Location: so ft. 150 ft. weathered rock/sand
Monica Frake 150 ft. 160 ft* solid rock
Facility/Owner Name Facility ID#(if applicable) 166 ft. +86 ft• brown soft rock
370 Ford Rd, Salisbury 28147 300 ft- 329 ft- brown soft rock
Physical Address,City,and Zip ft. ft.
Rowan 334 302 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35 42 59.979 N 80 33 13.921 W
6.Is(are)the well(s)OX Permanent or OTemporary Si ure o Certified Well Contractor Date
By.signing this form,I hereby certify that the weil(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or MNo with 1 SA NCAC 01C.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 of the copy of this record has been provided to the well owner.
repair tarder k21 remarks section or on the back afehis forte.
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 I 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: 370 (ft-) 24a. For All Wells: Submit this foam within 30 days of completion of well
For multiple wells list all depths ifd&rent(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,
1f water level is above casing,use"-a" 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) 1 Method of test: weir 24c.For Water Suooly&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
clorine 17 oz completion of well construction to the county health department of the county
13b.Disinfection type: Amount: P tY p
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources{ Revised 2-22-2016
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