GW1--01792_Well Construction - GW1_20240320

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WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14.WATER ZONES 4 ! '
Well Contractor Name FROM TO DESCRIPTIONI
4449-A 240 it 260 ft. 1 GPM 1
ft. ft. 1
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased wells)OR LINER(if op &able)
Rowan Well Drilling FROM TO. DIAMETER ! THICKNESS MATERIAi.
Company Name 0 ft 105 ft 61/4 in. SDR21 PVC
404661 16.INNER CASING TUBiNG(geothermal closed-loop)-
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County.Stab Variance,etc.) ft ft In.
in-
3.Well Use(check well use): ft. ft.
Water Supply Welt FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural IDMunicipal/Public 0 ft ft. in.
Geothermal(Heating/Cooling Supply) EiResidential Water Supply(single) tit, ft in. '
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT -
Irrigation FROM TO MATERIAL , EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 it Holeplug; Gravity 30 bags
Monitoring DRecovery ft. ft.
Injection Well:
ft ft
Aquifer Recharge DGroimdwater Remediation
19.SAND/GRAVEL PACK(if applicable):
Aquifer Storage and Recovery IDSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test oStormwater Drainage ft ft
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary) ,
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(solo,hardness,sovrocictrpa grain ire etc.)
0 it 20 ft. Red Clay
4.Date Well(s)Completed:1/22/24 Well n#404661 20 ft 50 it Sandy Overburden
5a.WellLocation: 50 ft' 95 it Broken Rock
Cindy Stiller 95 it 105 ft Solid Rock
ftFacility/OwnerName - _ - FaciiityID#(ifapplicable) it
4645 Bringle Ferry Rd, Salisbury 28146 ft ft. '.-i ../Li'.k.14 L.,,
Physical Addams,City,and Zip ft ft. MAR 9 yl n 2024
Rowan 608 211 21.REMARKS
I
County Parcel Identification No.(PIN) -
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: CYiN0.i 3O(
(if well field,one lat/long is sufficient) 22. erification:
35 38 37.241 N 80 23 46.474 w ,i' j Jzz-i i f'
6.Is(are)the well(s))X Permanent or Temporary Signature of 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: DYes or X}No with 15A NCAC 02C.0100 or ISA NCAC 02C:0200 Well Construction Standards and that a
If this is a repoin fill out btowm 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:1 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 IIfdiferent(example-3Qa 200'rind2(4)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:6 010 24b.For Injection Wells: In addition to sending the form to the address in 24a
Rotaryabove,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) 1 Method of test weir 24c.For Water Supply&Iniection1 Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
chlorine 16 OZ completion of well construction to the countyhealthdepartment of the county
Disinfection type: Amount: mP
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016