GW1--03320_Well Construction - GW1_20230512

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only.
1.Well Contractor Information:
Spencer Adams
J.,
.14.WATER ZONES"
Well Contractor Name FROM TO DESCRIPTION I
CA 285
4449-A
NC Well Contractor Certification Number
15.OUTER CASING for
Rowan Well Drilling FROM TO DWIMER THICKNESS I MATERIALCompany Narno 0 ft- 1 64 ft. 6114 In. dr2l V PVC W galvanized
I&INN'ERcAsmow ING(Peothernialcl6nd4orip).
2.Well Construction Permit#: NA FROM I TO I DIAMETER THICKISM MATERIAL
List all applicable well construclianperians(i_e.TXC,Conno',State,Variance,etc.) f, ft- in.
3.Well Use(check well use): ft ft. in.
Water Supply Well: .17.SCREEN '
FROM TO DIAMETER THICKNES�S I MA RUL
SLOTSIZ E
Agricultural OMunicipal/Public ft. it in.
Geothermal(Heating/Cooling Supply) [3Residential Water Supply(single) ft.
ft is
Industrial/Commercial DResidential Water Supply(shared)
.181 GROUT
Irri2tion FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft. Holeplug Gravity 10 bags
DMonitoring [3Recovery ft. ft
Injection Well: —-ft. ft.
3Aquifer Recharge InGround%vater Remediation —FTS—ANDIGRAVEL PA tifabplieablel:
nAquifer Storage and Recovery OSalinity Barrier FROM I TO MATERIAL I E.NO L A.CEMEN-r MEMOD
Aquifer Test E)Stormwater Drainage ft. &
Experimental Technology [3Subsidence Control ft. ft. I
Geothermal(Closed Loop) []Tracer .20.DRILLING LOG ilidditionall W"4f.n­e­ce9-sar
Geothermal(Heating/Cooling Return) nOther(explain underfi2l Remarks) I FROM To DESCRIPTION(coler.buldnem mili'mck &be.ale-)
o % 18 ft* Clay
4.Date Well(s)Completed:4/25/23 Well ID#NA 18 ft. 30 ft. Sandy Overburden
Sa.wen Location: so ft. 54 & Broken Rock
54 64 It- Solid Rock _Li Vt
Garrett Bean L'R
Facility/Owner Name Facility ID#(ifripplicable) Ill. P
66 Broken Rock 1
1120 Leonard Rd, Salisbury 28146 ft- ft. MAY i,; 2LVLJ
Physical Address,City,and Zip fL ft. JW"
Rowan NA 21 REMARKS
County Parcel Identification No.(PIN) 56'galvanized. 8 ,SDR91 PVC. rasing
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one fat/long is sufficient)
354219.152 N 80 21 43.218 1.7 Z'
6.Is(are)the welf(s)OPermanent or OTemporary Signature oftcrtified_Weil Contractor Date
By signing this form,I hereby cert#y that the walls)was(W ere)constructed in accordance
7.Is this a repair to an existing well: OYes or EJNo with 15A XC4C 02C.0100 or 15A XCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out hitmi-it well construction information and eviplain the nature of the copy of ibis record has been provided to the well owner.
repair under P21 remarks section or on the.back ofthis form. 23.Site diagram or additional well details:
8.For Geoprobe/DP]r 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:I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:.485 —00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple 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,
lfwater level is above casing,use"-P" 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 well
12.Well construction method: construction to the following:
(i.e.auger,-tam cable,direct push.etc.)
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,'Raleigh,NC 27699-1636
131a.Yield(gpm) 2.5 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-. 22 oz completion of well construction to the county health department of.the county
where constructed.
Form GW-1 North Carolina Department ofFavironmentat Quality-Division of Water Resources I Revised 2-22-2016