GW1--08018_Well Construction - GW1_20231214

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WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only:
I.Well Contractor Information:
Spencer Adams 14.WATER ZONES
Well ContractarName FROM TO I DESCRIPTION
4449-A 63 ft 120 ft. 2 GPM
NC Well Contractor Certification Number 120 ft. 300 s ft 2 GPM
15.OUTER CASING(for multi-cased wells)OR LINER fife livable)
Rowan Well Drilling FROM TO > DIAMETER THICKNESS MATERIAL
Company Name 0 ft' 63 61/4 m. SDFt21 PVC
400477-1 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO + - DIAMETER THICKNESS .MATERIAL
List all applicable well construction permits(Le.UIC,County.State,Variance,eta) ft • It In.
3.Well Use(cheek well use): ft ft. In.
Water Supply Well: 17.SCREEN
Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
gn DMunicipaliPublic 0 s. ? • in.
Geothermal.(Heating/Cooling Supply) DResidential Water Supply(single)
Industrial/Commercial DResidentialWater Supply(shared) 18.GROUT
Irrigation FROM TO ' MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 t ff. Holeplug Gravity 13 bags
Monitoring (JRecovery R. f3t.
Injection Well:
ft ft
Aquifer Recharge QGroundwater Remediation
Aquifer Storage and Recovery �{Sa]�i Bam� 19.SAND/GRAVEL PACK Of applicable)
tJ tY FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test tStormwater Drainage ft ft
Experimental Technology 0Subsidence Control ft. , ft.
Geothermal(Closed Loop) [JTracer 20.DRILLiNG LOG(attacti additional sheets if necessary)
Geothermal(Heating/Cooling Return) flOther(explain under#21 Remarks) FROM TO t DESCRIPTION(color,budges mWrnektvPe Min tire,eta)
0 ft
4.Date Well(s)Completed:11/14/23 Well ID#400477-1 5 ft 53 ; ft- Sandy;Overburden
Sa.Well Location: 53 n 63 ' f. Solid Rock
Zack& Danielle Brown 63 ft. 100 tan/white rock/soft
Facility/OwnerNane Facility RV(ifapplicable) ft. ' ft
2520 Gheen Rd, Salisbury 28147 ,t. •-
Physical Address,City,and Zip ft ft.
Rowan 317 006 21.REMARIfs (1F C I % 202?
County ParcelIdentifcalionNo.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I f.lrti`::::',J
(ifwell field,one latiiong is sufficient) 22.Certification:
35 43 41.453 N 80 32 3.190 W t '1 � ` 1 � ,�
t._
6.Is(are)the wells)jPermanent or ['Temporary Stgaannc o Certified Welt Contractor Date
By signing this forma,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [Yes or [X No with 1.5.4 NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this Is a repair,fall out known well construction information and explain the native of the copy ofthis record has been provided to the well owner.
repair under#21 remarks section or on the backofthisform • 23.Site diagram or additional well deta ls:
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 TOTALNUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:1 SUBMITTAL INSTRUCTIONS '
9.Total well depth below land surface:305 (ft.) 24a. For MI Wells; Submit this form within 30 days of completion of well
For multiple wells list all depths((fthferent(example-3Q200'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 Infection 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: 1
(i.e.anger,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 tesb weir 24c.For Water Sunray&Infection'Wells: In addition to sending the form to
Chlorine 14 02 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 14 of well construction to the county health department of the county
where constructed. '
Farm GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016