GW1-2022-10261_Well Construction - GW1_20221114

WELL CONSTRUCTION RECORD (GW--b For Internal Use Only: RECS
1.Well Contractor Information:
Spencer Adams 14.WATERZONES- N 071 1- J,_9 n
Well Contractor Name -FRONT —-TO DESCRIPTION
200 ft- 3D0 ft- 1 1r2 OR I
4449-A
NC Well Contractor Certification Number
-15.OIJTERCglNa(foi 'Wells)P&LAER LifaVY61310
THI V
FRONT �ESS
Rowan Well Drilling �!DIIANRM MATERIAL
0 ft- 1 73 . It' 61/4 in- SDR21 PVC
Company Name
A6X4NER CASING OR
2.Well Construction Permit#:357345 FRONT TO DIANIET]ER THICKNESS MATERIAL
Lisl all applicable well construction permits(4e.UIC,County,Slate,Variance,etc.) ft. ft. in.
3.Well Use(check well use): tt. tt. in.
_17. -SC REEN
Water Supply Well: FRONT TO DL"Wff.R:T—SLOT SIZE TirickryEss MATERIAL
JAgricultural [3Municipal/Public ft. ft. in. I
"IGeothermal(Heating/Cooling Supply) iResidential Water Supply(single) ft. ft. in.
:)Industrial/Commercial []Residential Water Supply(shared)
-I&GROUT:
lIrrigation FROM.. TO 51ATERUL FNIPLAMMENT METHOD&ANIOUNT
Non-Water Supply Well: 0 ft- 20 ft. Holeplug Gravity 6
:3Monitoring [3Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge OGroundwater Remediation
19 SANDIGRAVELTACK(ifapolicfible): ...
DAquifer Storage and Recovery 13Salinity Barrier FRONT TO MATERIAL EMPLACEMENT 5.I.E.T.HOD
:)Aquifer Test [3Stormwater Drainage ft. ft.
_lExperimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) [3Tracer
RGeothermal(Heatin Cooling Return) nOther(explain under#21 Remarks) J FROM I TO DESCRIPTION(color,hardness,sollfrock type.grain siz etc.)
0 ft- 12 ft* Clay/Sand
4.Date Wells)Completed; 10/11/22 Well 1011357345 12 ft. 40 ft. Sandy ovedxuden
5a.Well Location: 40 ft. 63 ft. Weathered Rock
Dick Palmore 63 ft. 1 73 ft- Solid Rock
Facility/Owner Name Facility ID9(ifapplicable) ft. ft.
1027 River Trace Lane, Salisbury 28144 ft. ft.
Physical Address,City,and Zip ft. ft.
--il.—REMARKS:
Rowan 307C271
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees-
(ifwell field,one Wong is sufficient) 22 C till ati n-
35454.482 N 80 28 13.200 W 10
6.Is(are)the well(s)opermanent or OTemporary Signature of Certified We Contractor Date
By signing this form,I hereby cerlifi,that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or E)NO with IJANCACO2C.0100 or 15A XCAC 02C.0200 Well Construction Stwidards and that a
Ifthis is a repair,fill out known,well construction information and explain the nature ofthe cojf;T of this record has been provided to the well owner.
repair wider#21 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 I GW-I 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; 405 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For in uIllple wells list all depths ifdIfferent(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,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I I.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 welt
.12.Weil 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 1/2 Method of test:weir 24c.For Water Supply&Injection 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.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016