GW1-2022-01474_Well Construction - GW1_20220120

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
CHAD HARTNESS -
.-�t'�5-,< � � �b-' 014:rtWATER7ZONE3
Well Contractor Name ;q�� � FROM TO I DESCRIPTION
ft- f4 1290
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2901 A 2 2�?2 289 fL
NC Well Co I for Certification Number
*1S:AOUTERCASI19G;f6r-%lli=ciM,,V8la'..ORiIINEW .E. "b*
AIR DRILLING INC FROM TO DIAMETER THICKNESS MATERIAL
Compaq Name t s i 0 ft 105 ft 6 '" PVC
igl6.$iNNER;- INGi0R0'(JBING1 eothe"r'm'7il!closed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) ft ft 1O
3.Well Use(check well use): fL It
Water Supply Well: -217.4SCREEN
FROM TO DIAMETER -SLOT SIZE THICKNESS I MATERIAL
OAgricultural ❑Municipal/Pubiic ft 2 in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fL p• in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) NlgyGROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 fL GROUT POURED
❑Monitoring ❑Recovery ft. fL
Injection Well:
ft. fL
❑Aquifer Recharge ❑Groundwater Remediation
9196SAWD/GRAYELVAGK if WO-51 ire b1
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage ft ft.
❑Experimental Technology ❑Subsidence Control ft. fL
❑Geothermal(Closed Loop) ❑Tracer 20.10RIL7:IlHGiIOGfaWchrA1ditiomMeheea`?if.ne«a
[]Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,F1nde WI/rocketc
0 f• 40 ft- DIRT
4.Date Well(s)Completed: 12-7-2021 Well HM 40 ft- 305 fL ROCK
5a.Well Location: % fL
KATHY NORRIS ft: &
Facility/Owner Name Facility ID#(if applicable) ft. ft.
343 RIMROCK RD,HARMONY,N.C. 28634 fL ft.
Physical Address,City,and Zip fL &
IREDELLIi�xEMARKs
County Parcel Identification No.(PIN)
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latAong is sufficient) erti6 on:
350 55.462 N 80e 44.308 W � 12/7 2 e' 1
/ 02
6.Is(are)the well(s): MPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,/hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ItNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 well Construction Standards and that a copy
If this is a repair,fill out known 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 (ft)
For multiple wells list all depths y'doerent(example-3©200'and 2(a3100') Submit this GW-1 within 30 days of well completion per the following:
I
50 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (fL) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Jfwater level is above casing,use"+" i
11.Borehole diameter: 6 24b.For Injection Wells:Copy to!DWR 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 he county m a department of tl3e.
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Cop
y to D WR,CCPCUA
139.Yield(gpm) 25 Method of test: AIR Perm—it gram,1611 MSC,Rateigh,NC 27699- 611
13b.Disinfection type: HTH Amount:
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources `, Revised 6-6-2018