GW1-2021-00857_Well Construction - GW1_20210305

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Chad Hartness 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
2901 A 0 ft' 400 r`' 1 P
400 ft, 545 ft, Remained 1 GPM
NC Weil Contractor Certification Number 15.OUTER CASING for multi-eased wells OR LINER if a licable
HickoryWell Drilling Co. , Inc. FROM TO DIAMt:I'ER THICKNESS MA7'F.RIAL
g 0 ft• 63 r`' 6 1/4 1n' SR211 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.well Construction Permit#: GIS 24756 FROM TO DIAMETER TifICKNF.SS MATERIAL
List all applicable well construction permils fl.e.U1C,County•,State, Variance,e1r.) ft. ft, in.
ft. ft. In.
3.Well Use(check well use):
Water Supply 17.SCREEN
PAY Well: FROM TO I DIAMETER I SLOT SIZE ITHICKNESS MATERIAL
Agricultural Municipal/Public 0 ft.
Geothernal(Heating/Cooling Supply) XoResidential Water Supply(single) ft. ft, in•
Industrial/Commercial r3Residential Water Supply(shared) 18.GROUT
irrigation FROM I TO MATERIAL I EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft.. 20 ft- Bentonite Poured from To
Monitoring ORccovcry ft. ft.
injection Well: ft. ft.
Aquifer Recharge r3Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
Aquifer Storage and Recovery MSalinity Barrier FROM TO J MATERIAL I EMPLACEMENTf METHOD
Aquifer Test C]Stormwater Drainage ft, ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color hardness soil/rock a Ain sin.etc.
Geothermal(Heating/Cooling Coolin Return) Other(explain under#21 Remarks)
0 ft' 55 ft' Dirt Clay.-Loose Rock
4.D ate Well(s)Completed: 0 2 19 2021 Well ID# 55 ft- 1545 ft- Granite Bed Rock
rL rt.
5a.Well Location:
fL ft.
Andy Smith - -v
Facility/Owner Name Facility 1D#(if applicable)
4089 River Rd. , Morganton, NC 28655 rt. rt.
ft. ft. V R X 0
2021
Physical Address.City,and Zip
Burke 21.REMARKS
Parcel Identification No.(PIN)
County •• �-"'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one[at/long is sufficient) 22.Certificatio .
35.665112 N 81.578950 W /03/2021
6.Is(are)the well(s)OPermanent or O'femporary
Signature of Certified Well Contractor Date
By signing this forth,1 hereby certtfi•that the mr//(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or:allo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known wed construction inforination and explain the nature q/the copy gflhis retard has been provided to the ivell owner.
repair tinder#21 remarks section or on the back of thisfibrin. 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 GAW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: / SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 545 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths lfdi/ferenl(exaniple-3@200'and 2(1,100') construction to the following:
10.Static water level below top of casing: 20 Est. (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 Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: Rotary Air Drilled
above, also submit one copy of this form within 30 days of completion of well
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) 1 Method of test: By Air Te s t 24c.For Water Suaaly&Injection Wells: In addition to sending the font to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Chl. Grans- Amount: 18 OZ s. (75%) 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