GW1-2022-01503_Well Construction - GW1_20220120

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
CHAD HARTNESS
14t WATER ZONES
Well Contractor Name a 0 ( FROM TO I DESCRIPTION
2901A 409 tt• 410 ft•
^r6Pa7` Ct ft. ft
NC Well Contractor Certification Number
�`t,;, tc^ J�j4p 15.OUTER"CASING forroulticasedwells OR LINER ifa licable
AIR DRILLING INCtiV•` FROM TO DIAMETER Tt11CKNESS MATERIAL
Company Name 0 ft. 143 ft.
6 in. PVC
311144 .16.INNER CASING OR TUBING(geothermal closed-10013
2.Well Construction Permit#: FROM I TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. R. in.
Water Supply Well: 17.SCREEN
FROM TO I DIAMETER I SLOTSIZE I THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public ft. tt. in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. rt. in.
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 1 0 e• 20 ft GROUT' POURED
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft.❑Aquifer Recharge ❑Groundwater Remediation ft.
19.SAND/GRAVEL PACK ifapplicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO I MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 1 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM I TO DESCRIPTION color,hardness,soil/rock type,prain size,etc.
0 ft' 133 ft• DIRT
4.Date Well(s)Completed: 8-27-2021 Well ID# 133 ft- 425 ft- ROCK
5a.Well Location: ft. ft
CORNERSTONE 3 PROP e. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
141 GRAY BARN DR, TROUTMAN,N.C. 28166
Physical Address,City,and Zip ft. ft.
IREDELL 4751166944 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) Cert ation:
350 42.204 N 800 50.508 q 8/27/2021
6.Is(am)the well(s): CJPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 15No 15A NCAC 02C•.0100 or l5A NCAC 02C.0200 Well Construction Standards and that a copy
/f this is a repair,fill out known spell construction information and explain the nature of the of this record has been provided to the well owner.
repair tinder 1121 remarks.section or on the hack 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 I 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: 425 (ft.
Formulliple wells list all depths ifdierent(example-3 rt✓i 200'and 2 rci 100') ) Submit this GW-1 within 30 days or well completion per the following:
10.Static water level below top of casing: 25 (it•) 24a. For All Wells: Original form;to Division of Water Resources (DWR),
If water level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 2769 9-1 6 1 7
11.Borehole diameter: 6 (in.) 24b. For infection Wells: Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 276`99-1636
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 I
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
10 AIR Permit Program, 1611 MSC,Raleigh,NC 27699-161 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: HTH Amount:
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Forst GW-I North Carolina Department of Environmental Quality-Division of Water Resources I Revised 6-6-2018