GW1--05105_Well Construction - GW1_20240827

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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 69 ft 100 h 10 GPM
4449-A 265 n' 300 R- 5 GPM
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cued wells OR LINER(If &able)
Rowan Well DrillingFROM TO DIAMETER THICKNESS MATERIAL
0 ft 65 f. 61/4 in. SDR21 PVC
Company Name 411744 16.INNER CASING OR TUBING(geothermal cloned-loop)
2.Well Construction Permit#: FROM r0 DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U/C,County,State,Variance,etc.)
ft. ft, ia.
ft ft. hi.
3.Well Use(check well use):
Water Supply 17.SCREEN
pp y Well: FROM TO DIAMETER SLOT SUE THICKNESS MATERIAL
°Agricultural °Municipal/Public 0 It. ft. ia.
°Geothermal(Heating/Cooling Supply) XDResidential Water Supply(single) R. ft. in.
ElIndustrial/Commercial °Residential Water Supply(shared) Hi.GROUT
()Irrigation FROM TO MATERIAL _EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 R• Holeplug _Gravity 5
Monitoring °Recovery ft. H.
Injection Well: ft. R.
Aquifer Recharge °Groundwater Remediation 19.SAND/GRAVEL PACK(If applicable)
Aquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
3Experimental Technology °Subsidence Control ft. R.
Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary)
PROM TO DESCRIPTION i`lor,Sardines,ooWVreek type,grata oluy etc.)
°Geothermal(Heating/Cooling Return) [Other(explain under 021 Remarks) 0 20 n clay
4.Date Well(s)Completed:7/24/24 Well»>#411744 20 n 60 It. sandy overburden
5a.Well Location: 60 Et• 65 ft* solid rock
Jim Brodnik 69 ft. 74 ix brown rock
Facility/Owner Name Facility ID#(if applicable) 90 ft. 100 1t• brown vein !` - i•'•i -— u
1455 Pop Eller Rd, Salisbury 28146 265 fL 270 °• brown vein ` '` a 1�`
Physical Address.City,and Zip ft. "• AUG 2 j 2 n 24
Rowan 354 187 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.Certification:
35 35 35.954 N 80 26 4.277 w �1 4 I-L 4
Signature of Certified Well Contractor Date
6.Is(are)the well(s)I Permanent or OTemporary
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 ISA NCAC 02C.0100 or 15.4 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 hay 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: 305 at) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple welts list all depths iidifferent(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 muter level is above casing,use"+" 1617 Mall 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:
(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) 15 Method of test:weir 24c.For Water SunDly&Inlection 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 GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016