GW1-2022-01507_Well Construction - GW1_20220120

WELL CONSTRUCTION RECORD(GW44 For Internal Use Only:
1.Well Contractor Information: n fv
CHAD HARTNESS '1;1O
14.WATER ZONES '
FROM TO DESCRIPTION
Well Contractor Name
2901 A 409 ft. 410 ft
ft k.
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased wells OR LINER if a licable
AIR DRILLING INC FROM TO DIAMETERi THICKNESS MATERIAL
0 ft 35 ft- 6 in GALV
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 228298 FROM TO DIAMETER! THICKNESS I MATERIAL
List all applicable well construction permits(i.e.U1C,County.State, Variance,etc.) ft ft. :in.
3.Well Use(check well use): ft. fa in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER •SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) InResidential Water Supply(single) fa k. in.
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑irrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEM ENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft- GROUT POURED
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK ifa licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(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,soi0rock a rain size etc.
0 ft. 25 ft. DIRT
4.Date Wells)Completed: 5-7-2021 Well ID# 25 ft 425 ft' ROCK
5a.Well Location: ft. ft.
PEACHTREE RESIDENTIAL ft. ft.
Facility/Owner Name Facility ID9(ifapplicable) ft. ft.
108 FAIRFAX CT, MOORESVILLE,N.C. 28117 ft. ft.
Physical Address,City,and Zip ft. ft
IREDELL 4624238063 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one IaUlong is sufficient) 2 e�''ficati --
35° 30.496 N 80° 56.220 W 1.a,f e�,
�- 5/10/2021
6.ls(are)the well(s): OPermanent or ❑Temporary Signature ofCertified well Contractor Date
By.signing this form,I hereby certify that the yell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or It No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
1f 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 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 l 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: 425 (ft)
For multiple wells list all depths ifdifferent(example-3@200'and 2@I00') Submit this CW-1 within 30 days Of well completion per the following:
20 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
I I.Borehole diameter: 6 (in,) 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 department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 12 Method of test: AIR {
13b.Disinfection type: HTH Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources j Revised 6-6-2018