GW1--04328_Well Construction - GW1_20240722

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Spencer Adams 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
4449-A 88 it 185 ft- 1 GPM_
185 ft 400 ft. 1 GPM_
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells R O LINER if a neable
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name
0 it 88 ft 61/4 in SDR21 PVC
249454 _
I6.INNER CASING OR TUBING eotbermal closed-1
2.Well Construction Permit# FROM TO DIAMETIR THICK-NESS MATERIAL
List all applicable well construction permits(i.e.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 SITE THICKNESS MATERIAL
Agricultural [)Municipal/Public 0 ft. ft in.
Geothermal(Heating/Cooling Supply) )Residential Water Supply(single) ft. ft, in.
Industrial/commercial [)Residential Water Supply(shared) 18.GROUT _
im atlon FROM TO MATERL\I. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 IL 20 ft. holeplu_g gravity 14 bags
Monitoring 13Recovery ft ft.
Injection Well:
ft. ft.
Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK f• 1lcttble
Aquifer Storage and Recovery [)Salinity Barrier FROM TO MATERI:%L EMPLACEMENT METHOD
Aquifer Test QStormwater Drainage IL ft•
Experimental Technology [)Subsidence Control ft ft.
Geothermal(Closed Loop) [)Tracer 20.DRILLING TAG attach additional sheets if necessary).
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks FROM TO DESCRIII-ION color,haMpess,wiUroct type,gntin size,etc.
0 ft 15 ft. clay
4.Date Well(s)Competed:5/6/24 well 113#249454 15 ft 78 ft. sandv overburden
5a.Well Location: 78 ft' 88 ft solid rock
Andrew Casasanta it ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
4190 St Peters Church Rd, Salisbury ft ft. _
Physical Address,City,and Zip ft ft' ,;.,�`'-f.? �-r•_� r
Rowan 637 060 21•REMARKS
County Parcel Identification No.(PIN) —
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 2.Certification:
35 35 17.922 8021 36.233
N W
6.Is(are)the well(s)0x Permanent or [)Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: [)Yes or X[)No with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 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: 405 (N 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 r@200'and 2Q100D 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
13a.Yield(gpm)2 Method of test:Weir 24c.For Water Supply&Iniecrion 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: 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