GW1-2022-01470_Well Construction - GW1_20220120

I
WELL CONSTRUCTION RECORD(GW 1)
For Internal Use Only:
1.Well Contractor Information: i
CHAD HARTNESS �'" 5�
m �v� 14'WATER
Well Contractor Name l t_
I �'eas` FROM TO
2901 A , 1 (� O �0�` 1�1at 289 ft 290 tL DESCRD`770N
fr.
NC Well Contractor Certification Number „r t; '{' ' FL
AIR DRILLING INC ^ 15 OUTER CASING for InWti�ikedwe"s It LINER,if 'liceble'}.
S ' J�;, FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 fL 95 fL 6 ! in
PVC
AP-3228871 16;INNER CASINGOR TUBING' eothermal'closed loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,eta) fL ft.
3.Well Use(check well use): fL ft. in
FOAgricultural
ter Supply Well: A7:SCREENA, 011!iU iit4 ,,'•. : , ,;a i; ? ,X,lii:i:, .re ea rna,a., .;
❑Municipal/Public FROM DIAMETERft fL in.
eothermal(Heating/Cooling Supply) OResidential Water Supply(single)dustriaVCommercial fL tt❑Residential Water Supply(shared)
a&GROUl at10n ❑Wel Is>100 000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:❑Monitoring ❑Recovery 0 ft. 20 fL GROUT POURED Injection Well: fL fL
❑Aquifer Recharge ❑Groundwater Remediation fL ft.
❑Aquifer Storage and Recovery ❑Salinity Barrier 19 SAND/GRAVEL PACK if a licatile
FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage fL fL
❑Experimental Technology ❑Subsidence Control L ft.
❑Geothermal(Closed Loop) ❑Tracer ;:20;.,]D;R.I;LL.G,LOG iatmeh additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM DESCRIPTION color hardness so10rock a rain size,ete.
0 fL 85 fL DIRT
4.Date Well(s)Completed: 12-15-2021 Well ID# 85
ft' 305 fL ROCK
So.Well Location: fa ft.
TOMMY BOWLES fL ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
501 PISGAH CHURCH RD,STATEVILLE, N.C. 28677 fL ft.
Physical Address,City,and Zip fL ft
IREDELL 4718427574 21.iliEMARKS
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) Ce teatiqu.
350 53.206 N 80e 58.370
7 ''Xk r` _—_.—"1P- 12/15/2021
6.Is(are)the well(s): InPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 8No 15A NCAC 02C.0100 or ISA NCAC 01C.0200 Well Construction Standards and that a copy
{jthis is a repair,fill out brown well construction information and explain the nature of the of this record has 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 construction info
construction,only 1 GW-1 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: 305 (fL)
For multiple wells list all depths if different(example-3 al 00'atd 2@100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 30 (ft.) 24a. For All Wells: Original form fo Division of Water Resources (DWR),
If water level is above casing,use"+' Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
t
11.Borehole diameter: 6 (in.) 24b.For Infection Wells:Copy to DWI,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: i
(i.e.auger,rotary,cable,direct push,etc.) 24c.For Water Supply and Open-Lod Geothermal Return Wells:Copy to the
county environmentaleal department,o e county w ere tnsta I
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells aroducine over 100 000 GPD Copy to DWR,CCPCUA
13a.Yield(gpm) 20 276
Method of test: AIR Permit Program,1611 MSC,Raleigh,NC 997611
13b.Disinfection type: HTH Amount: f�
f
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6.2018