GW1-2021-06292_Well Construction - GW1_20210915

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
gNll
Chad Hartness <'N 14.WATER ZONES
Well Contractor Name ru
FROM TO DESCRIPTION
2901 A �' �j T% `� ft' 180 r`' 1/2 GPM
1 ���� ft. ft.
NC Well Contractor Certification Number �� �Otr��pA 15.OUTER CASING for multi-cased wells OR LINER if applicable)
Hickory Well Drilling Co. , Inc��anC�c'�, FROM fL TO ft DIAMRI'ERin THICKNESS MATERIAL
1] 6 1 4 SR211 PVC
Company Name V% —� 16..INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: WELL-04-2021-148893 FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC.County,State, Variance.err.) ft. ft. in,
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
PP Y FROM I TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft.
73 Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
hTl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 r`' 20 f" Bentonite Poured from To
Monitoring 0Rccovcry rut. rut.
Injection Well:
Aquifer Recharge DGroundwater Rerrediatiou
19.SAND/GRAVEL PACK if a licable
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3 Stormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. tt.
Geothermal(Closed Loop) oTracef 20.DRILLING LOG attach additional sheets if necessary.)
FROM TO DESCRIPTION color,hardness oil rock type,grain size,etc.
Geothermal (Heating/Cooling Return) MOthcr(explain under#21 RemarksLJ ft- Clay
0 ft• 110 • Dirt' Loose Rock,
4.Date Well(s)Completed:0 7—13—2 0 2 1 Well iD# 110 f`' 225 f" Granite Bed Rock
ft.
5a.Well Location: ft.
Andrea Rogers rc. rc.
Facility/Owner Name Facility iD#(if applicable)
1924 Houston Mill Rd. , Conover, NC 28613
Physical Address.City,and Zip
Catawba 374419720196 21.REMARKS
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.CertifiCatio
35.769426 N 81.200954 W 2Z.2 e, 7-- 09/08/2021
6.Is(are)the well(s)oPermonent or Temporary
r e ificd II tra or Date
Bp signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: InYes or 3ONo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction lnftrmation and explain the nature of the cops of this record has been provided to the well aryner.
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: N/A SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 225 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdioerent(example-3@200'and 2tw100') 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
Rotar Air Drilled above, also submit one copy of this form 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,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 15 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: 7 Oz S. (7 5�� 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 Rcsourcesi Revised 2-22-2016