GW1--01029_Well Construction - GW1_20240212

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4449-A 63 ft- 120 ft- 2 GPM
120 ft• 300 ft• 2 GPM
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased welts)OR LINER(If ap licable)
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 63 ft- 61/1 in' SDR21 PVC
Company Name
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(i.e.U1C,County,Stale,Variance,etc.) ft. ft. In.
3.Well Use(check well use): ft. ft. in
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public 0 ft. ft. ,n.
Geothermal(Heating/Cooling Supply) XQResidential Water Supply(single) fL ft. in.
industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation • FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft- Holeplug Gravity 13 bags
Monitoring DRecovery ` ' ft. ft.
Injection Well: —
ft. ft
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [JStormwater Drainage ft ft.
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if newsy ([,f —Jy i J) �j'"�)
of D FROM TO DESCRIPTION(color,hardaefs,sofieathdip%—iaY.a..)V?V
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks)
11/14/23 400477-1 0 15 clay FED 1. 2 20c4
4.Date Well(s)Completed: Well ID# _ 15 ft 53 Saner Overburden
Sa.WelLocadon: 53 ft. 63 ft' Solid Rock tnkrlr.4:iea FirW. '.2 unit
Zack & Danielle Brown 63 ft- 100 ft' tan/white rock/soft D Gl9OG
Facility/ Name Facility lD#(if applicable) ft. ft
)530 Gheen Rd, Salisbury 28147 ft.
Physical Address,City,and Zip ft
Rowan 317 006 21.REMAR
County Parcel Identification No.(PIN) ( 5 (1'Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: CC S LID
��
(if well field,one tat/long is sufficient) 22.Cerdfica Vi
35 43 41.453 N 80 32 3.190 w
Piti
6.Is(are)the well(s)DX Permanent or Temporary Signature o�Ce v. /
By signing this
7.is this a repair to an existing well: DYes or ONo with 15A NCA( 1
If this is a repair,fill out known well construction information and explain the nature of the copy of this reu " LS5 ,
repair under#21 remarks section or on the back of this form.
23.Site dings
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use �1/�- id[
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction d VI �
drilled:1 SUBMITTAL
9.Total well depth below land surface: 305 (ft) 24a. For All
For multiple wells list all depths if different(example-3 00'and 2®1001 construction t,
10.Static water level below top of casing: (ft.) Div] _ ...6
If water level is above casing,use"+" 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 (In.) 24b.For Iniecdon 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
13a.Yield(gpm)4 Method of test:Weir 24c.For Water Supply& Iniecclgn 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: 14 OZ completion of well construction to the county health department of the county
where constructed.
Form G W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016