GW1-2022-01528_Well Construction - GW1_20220120

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
CHAD HARTNESS `
e `*.q• 14.WATER ZONES-
a`-2, n n�� FROM TO DESCRIPTION
Well Contractor Name a, . 389 rL 390 ft
2901 A - �C1%
© ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a Iicable
AIR DRILLING INC A �� FROM TO DIAMETER! THICKNESS MATERIAL
�� 0 fL 135 ft. 6 in. GALV
Company Name 16.INNER CASING OR TUBING eother a[closed-loop)
2.Well Construction Permit#: 316704 FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C.Cou_g'State, Variance,etc) ft ft, in.
3.Well Use(check well use): fL ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) InResidential Water Supply(single) ft. ft. in.
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl atlon ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT 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 if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage fr. ft.
❑Experi mental 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 I TO DESCRIPTION color,hardness,soiltmck type,grain size,etc.
0 ft- 125 ft- DIRT
4.Date Well(s)Completed: 5-19-2021 Well ID# 125 rL 405 ft- ROCK
5a.Well Location: ft. ft.
MICHELLE BROWN ft. ft.
Facility/Owner Name Facility ID4(if applicable) ft. ft.
612 ISLE OF PINE,MOORESVILLE, N.C. 28117 ft ft.
Physical Address,City,and Zip
ft. ft.
IREDELL 4635357982 21.REMARKS
County Parcel Identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22CIcatio
35032.155 N 800 54.103 W
§/19/2021
6.Is(are)the well(s): InPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.is this a repair to an existing well: ❑Yes or ONo 15A AICAC 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 Qfthis 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 l 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: 405 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdierent(erample-3@200'and 2@100')
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 it above casing,use
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
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gP m) 5 Method of test- AIR Permit Program,1611 MSC,Raleigh,NC27699-1 61 1
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13b.Disinfection type: HTH Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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