GW1-2022-01508_Well Construction - GW1_20220120

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
9, �y
CHAD HARTNESS '°'"
n 14.WATER ZONES
Well Contractor Name 1 A n - FROM TO -DESCRIPTION
JNI2OGC ' 389 ft- 390 ft.
trt �c2901A '
NC Well Contractor Certification Number ,'if G ft ft
r `` 15.OUTER CASING for multi-casediwells OR LINER if a licable
AIR DRILLING INC FROM TO DIAMETER THICKNESS MATERIAL
Company Name
0 ft 116 ft. 6 in. PVC
AP-31 3665' 16.INNER CASING OR TUBING eothermal closed-loon)
2.Well Construction Permit#: EFRTO DIAMETER THICKNESS MATERIAL
List all applicable iveR construction permits(i.e.U1C,County,State, Variatnce;etc.) ft. in.
3.Well Use(check well use): ft. in.
Water Supply Well: EN
TO .DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic ft. in.
❑Geothermal(Heating/Cooling Supply) nResidential Water Supply:(single) ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) T
❑irrl ation ❑Wells>100,000GPD TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 20 ft. GROUT. POURED
❑Monitoring ❑Recovery ft. fL
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑StormwaterDrainage fL ft.
❑Experimental Technology '❑Subsidence Control ft. I ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necesse
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soitIrock type,grain size.etc.
0 ft- 106 ft- DIRT
4.Date Well(s)Completed: 8-13-2021 Well ID# 106 ft• 405 ft. ROCK
5a.Well Location: fL ft.
MID ATLANTIC STRUCTIONEERS ft. ft.
Facility/Owner Name Facility ID#(if applicable) fL ft.
226 ROWAN RD,CLEVELAND,N.C. 27013 ft. ft.
Physical Address,City,and Zip ft. ft.
IREDELL 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude io degrees/minutes/seconds or decimal degrees:
(ifwell field,one IaUlong is sufficient) atiD35042.597 N80045.507 rJuerf-C z =---
8/13/2021
6.Is(are)the well(s): [!]Permanent or OTemporary Signature of Certified Well Contractor i 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 MNo !SA NCAC 02C.0100 or 15A NCAC 02C 10200 Well Construction Standards and that a copy
lfdnis•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 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 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: 405 (ft)
For multiple uW/s list o/1 depths ifd Brent(erample-3@200'and 1@100') Submit this GW4 within 30 days of well completion per the following:
10.Static water level below top of casing: 50 (- 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 27699-1617
i
11.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 aroducine over 100,000 GPD:Copy to DWR,CCPCUA
10 AIR Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: sff
13b.Disinfection type: HTH Amount:
f .
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018