GW1-2022-01524_Well Construction - GW1_20220120

WELL CONSTRUCTION RECORD GW-1 ., For Internal Use Only:
1.Well Contractor Information:
CHAD HARTNESS � `\, !`�'� 14.WATER ZONES
Well Contractor Name mod' � , FROM TO DESCRIPTION
�ti fL ft.
2901 A '�' �• 589 560
�� \i V GPO.1�' ft. ft
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased wells OR LINER if a livable
AIR DRILLING, INC ��� FROM TO DIAMETER THICKNESS MATERIAL
y 0 ft. 160 ft. g in. I PVC
Company Name ti.��
311079 ��• 16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U/C,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public fL ft. in.
❑Geothermal(Heating/Cooling Supply) In Residential Water Supply(single) ft. ft. in.
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lrri ation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 rr 20 rt• GROUT POURED
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ifa liable
❑Aquifer Storage and Recovery ❑Sal inity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
i
❑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,soil/rock We,grain size,eto
0 fL 50 ft- DIRT
4.Date Well(s)Completed: 3-10-2021 Well ID# 50 IL 605 ft- ROCK
Sa.Well Location: ft ft.
PHILAS EUDY It. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft ft.
234 RED HAWK LANE OLIN,N.C. 28660 ft. rt.
Physical Address,City,and Zip ft. ft.
IREDELL 4850069073 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one hit/long is sufficient) ertiri on:
35o 57.003 N 80o 51.288 W �-- -
3/10/2021
6.Is(are)the well(s): 19Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,/hereby cert�that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo iSA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
if this it 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 421 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 i 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: 605 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3 rt 00'and 2@100')
10.Static water level below top of casing: 60 (ft.) information
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
I1.Borehole diameter: 6 (in,) 24b. For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 276l99-1636
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
13a.Yield(gP m) 10 Method of test: AIR Permit Program,1611 MSC,Raleigh,NC 27699-161 I
13b.Disinfection type: HTH Amount:
I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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