_Well Construction - GW1_20230320 (31)

WELL CONSTRIICTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 44 WA-M WNM
FROM TO DESCRIPTION
Well Contractor Name 45 ft. igo ft. 9 cvm
4449-A ft. ft. i
NC Well Contractor Certification Number IS.,OUTER'CASING:for muitr-cased wells`,OR LMR'if a' Uca61e
Rowan Well Drilling FROM I To DIAMETER THICKNESS MATERIAL
0 ft. 48 ft.
61/4 1°' SDR21 PVC
Company Name 16.INNER CASING ING eotwimmal closed400
381509 FROM TO DUNIETER THICKNESS BATERIAL
2.Well Construction Permit#: it. ft. in.
List all applicable well construction permits(i.e.WC,County.State.Variance,etc.)
ft. ft. 1n
3.Well Use(check well use):
?17 SCREEN
Water Supply Well: FROM I TO IDIAMETER I SLOT SIZE I THICKNESS i1TATERTAL
Agricultural C]Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) x)Residential Water Supply(single) g, ft.
IndustriaUCommercial OResidential Water Supply(shared) MG `:-
Irrl ation FROM TO - bUTERiAL I 0,1PLAMIENTMETHOD&AMOUNT
Non-Water Supply Well: o ft- 20 ft• Holeplug Gravity 6 bags
Monitoring Recovery ft. ft.
Injection Well: ft. ft.-
Aquifer Recharge E3 Groundwater Remediation
19;:SAND/GRAVEL PACK atao 7icable
Aquifer Storage and Recovery [3Salinity Barrier FRONT TO MATERIAL EMPLACEMENTb1ETHOD
Aquifer Test [3Stormwater Drainage it: ft.
Experimental Technology Subsidence Control ft, ft.
Geothermal(Closed Loop) Tracer ::20 DRILLINGLOG`attach iiddiddii4l h&ts if iik&ia'
FROM TO DESCRIPTION color,hardness soiUrock e n size eta
Geothermal(Heatin Cooling Return Other(explain under#21 Remarks) 0 ft. 20 ft. May
2/18/23 381509 20 ft. 3o ft. weatherer Rode
4.Date Well(s)Completed: Well ID#
30 ft. 4S ft. Solid Rock
5a.Well Location:
Chase Roseman 45 ft. 165 ft. Numerous Brown veins
Facility/Owner Name _ Facility IDS(ifapplicable) f<• tt. T
265 Duckhom Rd, Salisbury 28146 ft. ft. a
W
ft. ft.
Physical Address,City,and Zip 707.1
Rowan 619131 .21.REMARxs a
I In
County Parcel Identification No.(PIN) { a t7
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22 Certification:
35 38 6.420 N 80 23 19.587 W I-S
6.Is(are)the well(s)fflPermanent or OTeroporary
Signature of Certified Well Contractor Date
By signing this fonn,I hereby certo that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or x®No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards mid that a
If this Is a repair,fill out known well constructioi information mid explain the nature ofthe copy ofthis record has been provided to the well owner.
repair under 421 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: 205 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200 and 2@100) construction to the following:
10.Static water level below top of casing: 14 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 161-7 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) 9 Method of test: weir 24c.For Water Sunuly&Iniection Wells: In addition to sending the form to
the address(es) above, also ssubmit one copy of this form within 30 days: of
13b.Disinfection type: chlorine Amount: 11 oz completion of well construction to the county health department of the county
where constructed.
,...., Unrih[amL'na nenartment of Environmental OuatitV-Division of Water Resources
Revised 2-22-2016