GW1--03318_Well Construction - GW1_20230512

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14.WATER ZONES I
Well Contractor Name FRO\I TO DESCRIPTION
60 ft. 185 ft. I GPM
4449-A
300 ft. 465 ft 3 GPM
NC Well Contractor Certification Number .15.OUTER CASING for multi-cased wells OR'LINER ifs licable)-..
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft 45 ft. 6114 ' in. SbR21 PVC
Company Name .16.INNER CASING OR TUBING eolhei nal closed-loop)
2.Well Construction Permit#:353362 FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,Corany,State,Variance,etc.) ft. ft. is
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17:SCREEN
FROM TO DmAWIER I SLOTSIZE THICKNESS I MATERIAL
:)Agricultural [3Municipal/Public ff. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
IndustriaUCommercial Residential Water Supply(shared)
18:GROUT
Itrl ation FROM - TO MATERIAI, EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Holeplug GRavity 14
Monitoring f Recovery ft. ft.
Injection Well: ft. ft
Aquifer Recharge 00roundwater Remediation
19.SAND/GRAVEL PACK if a fluble
I_ Aquifer Storage and Recovery DSalinity Barrier FROM To MATERIAL I EMPLACEMENT METHOD
Aquifer Test E)Stormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer -:20.DRILLING LOG attach additional sheets if necessa
Geothermal(Heating/Cooling Return) i, Other(explain under 421 Remarks) FROM To DESCRIPTION color,hardness,soiUrock le size.tic.
0 ft. 20 ft. Clay
4.Date Well(s)Completed:4/13/23 Well ID#353362 20 ft. 35 ft. Weathered Roth
5a.Well Location: ,s ft- 45 ft. Solid Rock
Mark Ridenhour ft. ft.
Facility/Owner Name Facility lD#(if applicable) ft. ft. �r R�i • , G
2494 Gheen Rd, Salisbury 28146 ft. ft.
Physical Address,City,and Zip ft. ft. MAY rd J
Rowan 312113 2LREMARKs rt- a ,.,
County Pazcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.Certification:
35 43 44.466 N 80 32 0.645 Wy
6.Is(are)the well(s)OPermauent or OTemporary Signature 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: []Yes or [9No with ISA NCAC 02C.O]00 or 15A NCAC 01C.0200 Mell ConstruGion Standards and that a
If this is a repair,fill out!attain well construction h formation mid explain the nature ofthe 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 l GW-1 is needed. Indicate TOTAL NUMBER ofwells construction details. You may also attach additional pages if necessary.
drilled:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 485 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2@100) construction to the following:
10.Static water level below top of.easing: (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 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 welt
(i.e.auugerr,,rotary,
,cable,direct push,.etc.).ae construction method. construction to the following:
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: W8ir 24c.For Water Suppiv&Iniection 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: 1.30Ibs completion of well construction to the county health.department of the county
where constructed.
I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016