GW1--05066_Well Construction - GW1_20230804

Pr rit Form'`,;
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14.WATER ZONES . : _ .
Well Contractor Name ;'^" ^+. , FROM TO DESCRIPTION
I�1.-V 4L:I V t-
4449-A 100 ft- 245 ft. 4GPM
ft. ft.
NC Well Contractor Certification Number A U G 0 4 2023 '-15:.OUTER-CASING(for multi=cased wells)OR LINER=(if ap liceble)
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
f �y ft. ft. in.
Company Name ,� d
396537 D�ite`+ry 3 `16.INNER CASING OR TUBING(geothermal closed-loop) " -—•
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft in.
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) 0Residential Water Supply(single) ft ft in.
Industrial/Commercial EpResidential Water Supply(shared)
i Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring EpRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge OGroundwater Remediation '
`49:SAND/GRAVEL PACK(if applicable)';` `
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology 0 Subsidence Control ft. ' ft
Geothermal(Closed Loop) OTracer r:20.,DRILLING LOG(attach additional sheets ifnecessary)''t= ..t:;
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,sotVrocktype Rain sae,etc)
0 ft• 100 ft- casing i
4.Date Well(s)Completed:7/6/23 Well ID#396537 too ft. 3A5 ft. red granite
5a.Well Location: ft ft.
Jennifer Robertson ft. ft.
Facility/Owner Name Facility RV(if applicable) ft. ft.
225 Zeb St,Salisbury ft. ft.
Physical Address,City,and Zip ft. ft.
Rowan 048 083 21.REMARKS'
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. edification:
3543 10.180 N 80 24 6.954 W
<LL.52--• ") 1cf 123
6.Is(are)the well(s){x Permanent or Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or ONo with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information 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 I 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: 345 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(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,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Inflection 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:
(ie.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) 4 Method of test:weir 24c.For Water Suooiv&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: 16 oz completion of well construction to the:county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016