GW1--03834_Well Construction - GW1_20230609

WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information:
Spencer Adams .14WATER<ZONEs
Well Contractor Name FROM TO DESCRIPTION I
4449-A 75 % too ft 2 aq,
200 fL 24o ft• r cue
NC Well Contractor Certification Number 15 OUTER"CASING'for'9mulG ci�sed we0'gMLR NER' f.a livable
Rowan Well Drilling FROM TO DIAMETER THICKNESSI MATERIAL
0 ft 1 37 ft 1 61/4 1- SDnl PVC
Company Name 382036 d'6 INNEWCASING Olt T BING' eothemiah'closed=loo _
2.Well Construction Permit#: FROM I TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC,County,State,Variance,etc.) % ft in.
3.Well Use(check well use): ft ft rn.
Water Supply Well: 41SCAEEN`-":"
FROM TO DIAMETER SLOTSIZE THICKNESS MATERWI.
Agricultural [3Municipal/Public ft ft in.
Geothermal(Heating/Cooling Supply) EiResidential Water Supply(single) ft fL in.
industrial/Commercial Residential Water Supply(shared)
711rrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft. Holeplug Gravity 8 bags
Monitoring DRecovery ft. fL
Injection Well:
ft. ft
Aquifer Recharge []GroundwaterRemediation 19 SAND/GRAVEL rfs` liable
- Aquifer Storage and Recovery Salinity Barrier FROM J To I MATERIAL I EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft I ft.
Experimental Technology 13Subsidence Control ft. I ft.
Geothermal(Closed Loop) OTracer -20 DRILLING LOG.'attncli'additional sheet§it
Geothermal(Heating/Cooling Return) rJOther ex lain under#21 Remarks FROM I TO DESCRIPTION color,hardness soittrock tym grain shr,etc
0 ft 20 ft, clay/quaNz
4.Date Wells Completed-5/10/23 Well ID#382036 20 ft 27 ft rya , v
()Com p weathered rock F •y cow.
5a.Well Location: 27 % 37 ft• solid rock
Chris Roseman 50 ft, 180 ft, various brawn veins J U N 6 9 2 Q2`
Facility/Owner Name Facility ID9(if applicable) ft ft
0 Bringle Ferry Rd,Salisbury ~
ft ft HnVvss v. uR51
Physical Address,City,and Zip ft ft
2L'REN/ARKS :,'' ;
Rowan 619129 " -
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.Certification:
35 38 7.339 N 80 23 20.121
6.1s(are)the well(s)�it Permanent or Temporary 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 [nNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction it formation and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 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-1 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: 245 (ft.) 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:25 (fL) Division of Water Resources,Information Processing Unit,
Ifirater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 6 (in.) 24b.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:
CLe.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 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: 12 oz completion of well construction to the county health department of the county
where constructed
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016