GW1--03833_Well Construction - GW1_20230609

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
i
Spencer Adams
Ia:wnTER zo;vEs:.
FROM TO DESCREMON
Well Contractor Name
225 ft, 240 ft' tt wee �
4449-A ft. ft.
NC Well Contractor Certification Number i3.0UTER`CASING furannld;cased-wells OR`LINER if 'cable
Rowan Well Drilling FROM To DIAntKILK TRICtav'ess I MATERUL
0 & 64ff 61l4 1°' SCR21 PVC
Company Name
,'1G.IIVNERCASINGORTUBING eothermalctosed=too
2.Well Construction Permit#'382891 FRONI I TO I I TIUCKNESS I MATERIAL
List all applicable well construction permits(i.e.WC,County,Srate,Variance,etc.)
ft ft. i°
it. ft
3.Well Use(check well use):
Water Supply Well: FROM I TO I DIAME[ER SLOTSIZE TMCKNESS %UTERML
Agricultural DMunicipaMblic ft ft iv
Geothermal(Heating(Cooling Supply) EiResidential Water Supply(single) g, n, la
lndustrial/Commercial DResidential Water Supply(shared) IS.GROIIC
-lIrrigation FROM - TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft, Holeplug Gravity 22 bags
Monitoring Recovery ft. ft.
Injection Well: tL ft.
Aquifer Recharge []Ground:iater Remediation
.79 SANDlGRAXEG'PACK if a hcable.>:'
Aquifer Storage and Recovery E3Salinity Barrier FROM TO MATERIAL E1tPLACE1s1ENThtE7I[On
Aquifer Test
Stormwater Drainage ft fL
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) 13Tracer =2o.ARILIsiNGiOG`nttricfiiiddfho>tal:sLeetslfneeesd'"
FROM TO DEScurnoN co tor hard sodlrock etc.
Geothermal eatin Conlin Return Othet(explain under#21 Remarks 0 tL 20 fL Clay
4.Date Well{s)Completed:5/11/23 well ID#382891 20 ft 4o f sandy overburden $ & I�+d't.
m fL ryq a
ft' weathered rock `°"�`•+e 1;-
5a.Well Location:
Angela Nystedt 54 fL 64 IL solldrock
J J
FacilitylOwnerName
Facility ID#(if applicable) 68 R brown rock
1086 Black Dog Lane,Salisbury 28146 90 ft- 110 ft, rrectutelgrave� lnbr*Af C l Prr.•C Aq nd
ft. % l?Ea
Physical Address,City,and Zip
Rowan 634155 zI.REAfARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees(minotes/seconds or decimal degrees: 22 Certification:
(if well field,one lat/loag is sufficient) ) � /
35 3418.237 N 80 23 4.872 w �t�.�
Signature ofCertified Well Contractor Date
6.Is(are)the well(s) Permanent or Temporary
By signing this jomb 1 hereby cerify that the uell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or ®No with 15A NCAC 02C.0100 or I5A NCAC 02C.0200 melt Construction Standards and drat a
Ifthis is a repair.fill out krmuvr well construction it formation and explain die nature afthe copy of this record has been provided to the well owner.
repair under i:21 remarks section or on the back of this form. 23.Site diagram or additional well details:
S.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 details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
Willed:r SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 265 (ft.) 248. For All Wells: Submit this form within 30 days of completion of well
For multipleweilslistalldepthsijdieren!(example-3t 00'and2@/00') construction to the following:
25 (ft.) Division of Water Resources,Information Processing Unit,
Ill.Static water level below top of casing: 1617 Mail Service Center,Raleigh,NC 27699-1617
ljwater level is above casing,rise"+"
II.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 276994636
Method of test:weir 24c.For Water SumDiv&Iniection Wells: In addition to sending the form to
13a.Yield(gpm) 2 the address(es) above, also submit one copy of this form within 30 days of
Chlorine Amount 12 cz completion of well construction to the county health department of the county
13b.Disinfection type: - where constructed.
016
Form GW-] North Carolina Department of Environmental Quality-Division of�VaterResources Revised.2-222Department