GW1--03837_Well Construction - GW1_20230609

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Wormation:
Spencer Adams Id:.WATER ZONE.&
FROM TO DESCREMON
Well CoutractorNama
114 f6 200 It, ,.scar il
4449-A a5 iL aw I
200 f4 3 asc
NC Well Contractor Certification Number '1S.`OIJTERCASMG:formitttt=easedwells UltLDVER lieabl
Rowan Well Drilling FROM TO DIAMETER ' THtCKN traEss MATERIAL
0 it 114 it. 61/4 in. SDR21 PVC
Company Name
":16;7NNER.CASINGOR7UBIiSG tbtliermalelosed=too
2.Well Construction Permit#: 335727 FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable hell construction permits(i.e.171C Coutity,State,Variance,etc.) it. ft. in.
3.Well Use(check well use): fR ft' in.
Water Supply Well: - FROM
TREE TO ..I DIAMETER SLOTS¢E.-...THICKNESS MATERIAL
Agricultural OMunicipallpublic ft. ft in..
Geothermal(Heating(Cooling Supply) EIResidential Water Supply(single) fL fL in
Industrial/Commercial Residential Water Supply(shared) 7jjZij5N
Irrigation - FROM TO MATERIAL EMPLACE6tENT METHOD&AMOUNT
Non-Water Supply Well: 0 it. 20 fL Holeplug Gravity a bags
Monitoring EIRecovery ft. R
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19 SAND/GRAVEti PAT 1C`rfe "lkable
LExperimental
r Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT:70
r Test E)Stormwater Drainage fL %
Technology Subsidence Control fa ft.
rmal(ClosedLoop) Tracer :2QDRILLINGLUG`attachaaditionalihietsiEnecessa[mel FROM TO DFSCRWIION(color.bmdn saiVrock
(Heating/Cooling Coolin Return) Other(explain Remarks) 0 ft. 10 ft: day
4.Date Well(s)Completed:5/2123 Well W#335727 10 ft: so ft. sandy overburden'
m ft. 104 & weathered rode
5a.Well Location: 1
Fidelia Arnoda 104 ft 14 ft so,d rock d a
Facility/Owner Name Facility ID9(ifapplicable) ft. ft. 1 q 7
3515 Carmi Lane, Salsibury 28144 (L ft.
k ft rn rr,.saa -3 lln
Physical Address,City,and Zip
Rowan
309 116 aL REI►fARLcs
county Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one laf/long is sufficient) 22.Certification;
35 44 30.774 N 80 29 20.606 W LZ
Signature ofCertified Well Contractor Data
6.Is(are)the well(s)oPermanent or OTemporary
By signing this form,1 hereby certify that the rrell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or x®No with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair.fill out known well construction information and explain the nature of the copy ofthis record has been provided to The well owner.
repair under 921 remarks section or on the back ofthis 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 1.is needed. Indicate TOTAL NUMBER ofvwetis
construction details. You may also attach additional pages if necessary.
drilled:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 385 (iG) 24a. For All Wells: Submit this form within 30 days of completion of well
par multiple wells list all depths ifdtTerent(example-3 it 200'and 2 J00.) construction to the following:
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
ifrrater level is above caring,use`+^ 1617 Marl 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,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Man Service Center,Raleigh,NC 27699-1636
139.Yield(gpm) 5 Methad 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- 18 oz 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