GW1-2021-03118_Well Construction - GW1_20210625

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Chad Hartness 14.WATER ZONES
FROM TO DESCRIP.TiON
Well Contractor Name
2901 A 0 f` 365 f` 6 GPM
ft tt
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER If a Ilcable
HickoryWell Drilling Co. , Inc. FROM TO DIAMETER THICKNESS MATERIAL
g ft. ft in.
Company Name 0 38 6 1/;4 SR211 PVC
16.INNER CASING OR TUBING oothermal closed-too
2.Well Construction Permit#: WELL-05-2021-150570 FROM TO I DIAMETER I THICKNESS I MATERIAL
List all applicable well construction pertnus(I.e.UIC,C.'ouno;.State, Variance,etc.) ft. ft I in,
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROM SCREENTO DIAMETER I SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public 0 ft. ft. in
Geothermal(Heating/Cooling Supply)X4MResidential Water Supply(single) ft. fr. inl
Industrial/Commercial OResidential Water Supply(shared) i87GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 f`• Bentonite Poured from To
Monitoring ORecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge E3Groundwater Remediation
19.SAND/GRAVEL PACK if a licablc
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage
Experimental Technology MSubsidence Control
Geothenal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness solUrock sin size etc.
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks)
0 f`' 1 33 ft, Dirt Loose Rock
4.Date Well(s)Completed: 06/09/202lyveliID# 33 f` 365 f`• Granite Bed Rock
ft. ft.
5a.Well Location:
Bruce Cloninger rc, rr. 1--
Facility/Owner Name Facility ID#(ifapplicable) ft ft.
6244 Gull Cove Lane, Conover, NC 28613
Physical Address.City,and Zip OCesgElerJ t)tll
Catawba 373511750256 21,REMARKS Itl�t n
County Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattiong is sufficient) a
n:
35 48'16" N 81 14' 9" W 06/24/2021
6.Is(are)the well(s)OPermanent or [3Temporary Signature ofCertificd Well Contractor ! Date
By signing this form,1 hereby certifi•that the Nr/1(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 13Yes or nNo with 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill our known well construction Information and explain the nature gfthe copy gfthis record has been provided to the well owner.
repair tinder#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
g.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: NSA SUBMITTAL INSTRUCTIONS'
9.Total well depth below land surface: 365 (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdigcrent(example-3@200'and 2CR,100') construction to the following:
10.Static water level below top of casing: 60 (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
Rotary Air Drilled above, also submit one copy of this fonn within 30 days of completion of well
12.Well construction method: y construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,lUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 6 Method of test: By Air Test 24c.For Water Supply&Infection 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:Chl. Grans. Amount: 13 OZ s. (7 5%). completion of well construction to'the county health department of the county
where constructed. j
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2.22-2016