GW1-2022-01531_Well Construction - GW1_20220120

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
CHAD HARTNESS - n �* 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2901A � © { � 289 ft 290 fL E
ft fL
NC Well Contractor Certification Number 1Q%-r�.`' 15.OUTER CASING for mulfi cased wells OR LINER if a licable
AIR DRILLING INC �� FROM TO DIAMETER THICrdYESS MATERIAL
0 ft 63 ft- 6 in.
Company Name
307055 16.INNER CASING OR TUBING eothermaI closed-loop)
2.Well Construction Permit#: \' FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC County,State, Variance,etc) ft ft. in.
3.Well Use(check well use): fL ft. in.
WaterSupply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public fL ft. in.
❑Geothermal(Heating/Cooling Supply) ItResidential Water Supply(single) ft. fL in.
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) I&GROUT
❑hTl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 20 ft- GROUT POURED
❑Monitoring ❑Recovery ft ft.
Injection Well:
fL ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 0 53 fL DIRT
❑Experimental Technology ❑Subsidence Control 53 ft 305 ft- ROCK
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return)
) ❑Other(explain under#21 Remarks) ft TO ft DESCRIPTION(color,hardness,soil/reck type,grain sae,etc
4.Date Well(s)Completed: 1-20-21 Well ID# It. ft.
5a.Well Location: rL ft.
BUELL BAKER It. ft-
Facility/Owner Name Facility iD#(ifapplicable) fL ft.
2614 BUFFALO SHOALS RD, STATESVILLE,N.C. 28677 ft ft
Physical Address,City,and Zip ft fL
IREDELL 21,REMARKS
County Parcel Identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iatflong is sufficient) 4 22.iCertiftealion.
350 41.815 N 800 59.409 w .� -
1/20/2021
6.Is(are)the well(s): MPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,l 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 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'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 iprovide 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: 305 (fL) i
For multiple wells list all depths ifdijferent(example-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 50 (fL) 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
"+" r
I I.Borehole diameter- 6 (in-) 246.For Infection 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-Lo p 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
6 AIR Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
13a.Yield(gpm) Method of test: I '
c
13b.Disinfection type: HTH289 Amount:
ii
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 6-6-2018