GW1-2022-01538_Well Construction - GW1_20220120

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
L Well Contractor Information:
ta,;sg•
CHAD HARTNESS 4n nJ
���'3 �• ".` 14.WATER ZONES
Well Contractor Name ' :� n, FROM TO DESCRIPTIONI
c` 240 fL 241 ft.
2901 A .,f `�
fL ft.
NC Well Contractor Certification Number A �� J� 15.OUTER CASING for multi cased wells OR LINER if a licable
AIR DRILLING INC FROM TO DIAMETERI THICKNESS MATERIAL
^` " '�,` 0 fL 85 ft. 6 in. GALV
Company Name `.
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM I TO DIAMETER, THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) ft. ft. lin.
3.Well Use(check well use): ft. ft.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER iSLOTSIZE THICKNESS MATERIAL
❑Agricultural I'Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrt ation ❑Wel Is>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 85 ft. TREMMIE GROUT
❑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 T EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage fL IL
❑Experimental Technology ❑Subsidence Control fL I 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,soiltrock type,grain size,etc.
0 fit- 75 fL DIRT
4.Date Well(s)Completed: 5-28-2021 Well ID# 75 fL 1005 R• ROCK
5a.Well Location: ft ft.
IREDELL WATER ft ft.
Facility/Owner Name Facility iD#(if applicable) ft. ft.
BEECHWOOD FARM 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 latflong is sufficient)
35033.942 800 52.195
6.Is(are)the well(s): ❑Permanent 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 NCAC 02C.0100 or 15A NCAC'02C A-700 Well Construclion Standards and that a copy
If 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 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 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: 1005 (ft.)
i-or multiple wells list all depths tfdierem(example-3@ 00'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
50 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
11.Borehole diameter: 6 (in.) 246. 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
I
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) 70 Method of test AIR Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount:
• i
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018