GW1-2023-01532_Well Construction - GW1_20230218

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: • '''. insim...7.
Spencer Adams 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
170 ft. 240 ft' 2 GPM
4449-A
240 ft- 340 ft. 2oat
NC Well Contractor Certification Number 1S.OUTER CASING(for multi-cased wells)OR LINER(if a liable)
Rowan Well Drilling FROM TO DIAMETER , THICKNESS MATERIAL
Company Name 0 ft. 133 ft' 6114 ill' sDR21 PVC
8 246 16.INNER CASING OR TUBING(geothermal dosed-loop)
3
2.Well Construction Permit#: 84 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County.State,Variance,etc) ft. ft. m.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural °Municipal/Public ft. ft. in.
°Geothermal(Heating/Cooling Supply) FriResidential Water Supply(single) ft. ft. in.
°Industrial/Commercial Residential Water Supply(shared) 1&GROUT
lIrrigation • FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft- 20 ft. hoteptug gravity 14 bags
Monitoring Recovery ft. rt.
Injection Well:
ft. ft.
DAquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
°Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test °Stormwater Drainage ft. ft.
°Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary)
°Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiVrock type,gain size,etc.)
0 ft- 20 ft- day
4.Date Well(s)Completed: 1/16/23 Well ID#384246 20 f• 123 ft' , sandy overburden
5a.Well Location: in ft' 133 ft. solid rod(
Mitchel Snider 145 ft' ias ft- brown softrock
Facility/Owner Name Facility ID#(if applicable) f L ft i E B 1 Z 0 23
245 Twin Lake Dr, Salisbury 28146 ft. ft.
In?:_,-,,Fes. . . ..3 1)r.::
Physical Address,City,and Zip ft ft .',.. ,
Rowan 603 111 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. ertifrcation:
35 41 22.220 80 22 16.337 !
_ i / t v /2 3
6.Is(are)the well(s)€x Permanent or ()TemporarySignature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or EINo with 15A NCAC 02C.0100 or ISA 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 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 1 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: 345 (f1-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells lot all depths if different(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
11.Borehole diameter: 6 (in.) 246.For Injection 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) 4 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: 16 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