GW1-2023-01534_Well Construction - GW1_20230218

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: tiommitemmor
1.Well Contractor Information: • `
Spencer Adams 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
23 ft- 910 ft- on urp,.n
4449-A
ft. ft.
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased wells)OR LINER(if ap bte)
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 23 ft. 61/4 in' SDR21 PVC
Company Name
382394 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.WC.County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. us.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural °Municipal/Public ft. ft, in.
°Geothermal(Heating/Cooling Supply) EiResidential Water Supply(single) ft• ft, i■.
°Industrial/Commercial ()Residential Water Supply(shared) IS.GROUT
IlIrrigation FROM TO MATERIAL , EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft• holeplug gravity 13 bags
OMonitoring Recovery ft. ft.
Injection Well: •
ft. ft.
Aquifer Recharge °Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
°Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
°Aquifer Test °Stonnwater Drainage ft. ft.
°Experimental Technology °Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
°Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/reek type grab,size,etc.)
0 ft. 13 ft. clay
1/15/23 382394 ft. ft.
4.Date Well(s)Completed: Well ID# 13 23 solid rock
Sa.Well Location: ft ft.
Harry Marsh ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. ' `-..-'.., , .c. '"':
510 Balfour Quarry Rd, Salisbury ft. ft. -.
'f 1:,
Physical Address,City,and Zip ft ft C i / - <
Rowan 353 118 21.REMARKS Iracr: ..,.. •: :' --
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, rtification:
35 36 9.411 80 26 41.577
N W i tiS1�3
6.is(are)the well(s)JPermanent or °Temporary Signature of Certified Well C6mtactor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or X°No with ISA NCAC 02C.0100 or 1SA 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 a21 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: 910 (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: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
1L 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) 0 Method of test: weir 24c.For Water SnDDIV& iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
I3b.Disinfection type: chlorine Amount: 2.5lbs 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