GW1-2022-01445_Well Construction - GW1_20220120

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
CHAD HARTNESS
�•_� 14.WATER ZONES
Well Contractor Name L FROM TO _ DESCRIPTION
2901 A Ail 2 2 n 309 ft. 310 ft. I
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased'wells OR LINER if a licable
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AIR DRILLING, INC �.,.Ut �iL'� ` v FROM TO DIAMETER TIIICKNF.SS MATERIAL
Company Name
0 ft. 114 ft• 6 in. GALV
02-2020'139080 16.INNER CASING OR TUBING eothermal closed-loon)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.(/1C,County,Slate, Variance,ele) ft• ft. in.
3.Well Use(check well use): ft. R. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE TIIICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) InResidential Water Supply(single) ft ft in
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUYr
Non-Water Supply Well: 0 fL 20 ft. GROUT POURED
❑Monitoring ❑Recovery ft. R.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO I MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft• ft.
❑Experimental Technology ❑Subsidence Control
0Gcolhermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain sin,etc.
0 a, 104 ft. DIRT
4.Date Well(s)Completed. 8-20-2021 Well ID# 104 ft• 325 ft. ROCK
5a.Well Location: ft. ft.
BLUEFIELD BUILDERS ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
4484 KISER ISLAND RD,TERRELL,N.C. 28682 ft. rt.
Physical Address,City,and Zip ft. ft.
CATAWBA 461602587074 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifvvell field,one Iaillong is sufficient) tificat
35° 34.105 N 80° 57.532 W Z��--�- -8/20/2021
C ''C
"1111;i
6.Is(are)the well(s): C1Permanent or ❑Temporary Signature ofCettified Well Contractor Date
By signing this fornt,I hereby certtfy that the Ire//(.t)Isms(u ere)constructed in accordance u'uh
7.Is this a repair to an existing well: ❑Yes or I!lNo 15A NCAC 02C.•.0100 or 15A NCAC 02C l0200 Nell Construction Standards and that a copy
lfthis is a repair,fi/l out known ive//construction information and explain the nature of the r f this record has been provided to the the//owner.
repair under#11 rennarks 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 construction info
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 325 (ft)
For multiple trel/s fist all depths ifdifferettt(example-3 a 200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 20 (R.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
lfsvater level is above casing,use"t" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b. For Iniection Wells: Copy to DiWR, Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal�Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm)
15 Method of test: AIR Permit Program, 1611 MSC,Raleigh,NC 27699-1611
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13b.Disinfection type: HTH Amount:
Font GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018