GW1--05070_Well Construction - GW1_20230804

Print Form; ;
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14.WATER ZONES. ..'
Well Contractor Name4449-A FROM TO DESCRIPTION
'. '>a--.e 4 s•^��,q) 185 ft. 225 ft• a cpu
ft. ft.
NCWell Contractor Certification Number R A U G 0 A 2023 '15;OUTER CASING'(for multi-cased:wells)OR LINER:(if'an'likable) . ,•. .
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name 4 0 fL 94 ft' 6 1/4 in* SDR21 PVC
ligGi`:Y4i•Vfl.iar",C7-W4>•�u =16;dNNER'CASING.OR TURING'(genthermalclosed400
391210 WA -
2.Well Construction Permit#:
t OG FROM TO DIAMETER THICKNESS)>. MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
-17.:SCREEN
Water Supply Well: FROM TO DIAMETER =.SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft ft. in.
Geothermal(Heating/Cooling Supply) -xResidential Water Supply(single) ft. ft. in.
Industrial/Commercial OResidential Water Supply(shared)
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft- 20 ft. Holeplug Gravity 8 bags
Monitoring EIRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge EiGroundwater Remediation =-19.SAND/GRAVEL--PACK(ifapplicnble)".. "'
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology 0 Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional shééla if necessary):fGFt '4"<'_
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rocktype,grain size,etc.)
0 ft. 10 ft. Clay I
7R23 391210
4,Date Well(s)Completed: Well ID# 10 ft sa ft• SandyOvemurden
5a.Well Location: 84 ft" 94 ft' Solid Rock
Palco 125 ft. 135 ft. Fracture
Facility/Owner Name Facility ID#(if applicable) 165 ft. US ft. Fracture
1081 River Trace Lane, Salisbury ft. ft.
Physical Address,City,and Zip ft. ft.
Rowan 307c274 21:REMARKS• '+ ,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
well field,one laUsuf
ficient)is 22.Certification:
35 45 1.666 N 80 28 13.353 W - L
1
n.�- Z3
6.Is(are)the well(s)J% Permanent or Temporary `"Signature f 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: QYes or ElNo 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 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: 225 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi 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,
If water 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:
(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 27699-1636
1 •
13a.Yield(gpm) 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: 11°z 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