GW1--01794_Well Construction - GW1_20240320

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams
19.:WATERZONES.:.'.'::•::'::...;.' .. :I': :.:.
Well Contractor Name FROM TO DESCRIPTION
4449-A 90 ft. 120 ft• 1 GPM I -
NC Well Contractor Cettification Number 350 '370 •ft 7 GPM
15 OUTER,CASING(for:multi-cased walk)OR LINER(If ap llcable):.:
Rowan Well Drilling FROM TO DIAMETER TTnCKNESS MATERIAL
CompanyName 0 ft. 190 e• 1 6 1/4 [In. SDR21 lPVC
402994 :16:INNER'CASING OR TUBING(geothermal dosed-loon) `:2.Well Construction Permit#: FROM TO DLAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. I in.
3.Well Use(check well use): ft. ft to,
Water Supply Well: 17 SCREEN
AgriculturalFROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
MunicipatPublic 0 t• ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
ft ft In
Industrial/Commercial
°Residential Water Supply(shared)
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 ft• Holeplug Gravity 13 bags
Monitoring E3Recovery ft. ft.
Injection Well:
ft. ft •
Aquifer Recharge °GroundwaterRemediation
Aquifer Storage and Recovery Salinity Barrier .'19.SAND/GRAVEL PACK(If applicable) . .
FROM TO MATERIAL EMPLACEMENT METHOD
:.
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology °Subsidence Control ft ft.
Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(tiitach additional sheets If necissaty) .,'"
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hasaneu,eoNroek tyc4 Mao&sa,etc.)
p 2/14/24 402994 0 it' 20 ft• Red Clay
4.Date Well(s)Completed: "�"�-_ P r
Well ID# 20 ft• 65 ft- Sandy Overburden �:-1.E�,..P .-t +e/ q ''
5a.Well Location: , 65 ft 80 ft' Weathered Rock
John Thomason 80 ft• 90 ft• . Solid Rock VAR `? 9 2[24
Facility/Owner Name Facility ID#(if applicable) 280 ft• 310 ft• Broken Rock - t'Y
4930 ConcordSalisbury28146 r� ''���).C.' `�''
Old Rd, �. �. '-n=',; '�`
350 370 Broken Rock Ci`�d�+1�'�'
Physical Address,City,and Zip ft. ft.
Rowan 411 059 z1 RElKAH1zs ::..: ;:. :'.. ...:::::
County Parcel IdentificationNo.(PIN) i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
35 35 56.504 N 80 29 37.364 22.C cation:
94_,QL_
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6.Is(are)the wells) }Permanent. or Temporary Signature of Certified Well Contractor j Date
By signing this form,I hereby cent(,that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: Oyes orX No with ISA 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:1
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 385 (ft.) 24a. For All this fount within 30 days of completion of well
Wells: Submit
For multiple wells list all depths different(example-3@200'and 2@100')
if
construction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"÷"
1617 Man Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 (In.) 24b.For Injection Wells: In additionCosending the form to the address in 24a
above,also submit one copy of this foist within 30 days of completion of well
12.Well construction method: rotary
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)8 Method of test:weir 24c.For Water Supply&Infection Wens: In addition to sending the form to
chlorine 18 Oz the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016
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