GW1-2022-01567_Well Construction - GW1_20220120

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WELL CONSTRUCTION RECORD(GW 1)
For Internal Use Only:
1.Well Contractor Information:
CHAD HARTNESS ~�o
14,WATER'ZONES
Well Contractor Name - O 20( FROM TO DESCRIPTION
AT
A Pit I 1 389 ft- 390 ft.
�r,
1 tee
NC Well Contractor Certification Number j,Jr L,: • ft ft. _
ji', ��.�01 '15.OUTER CASING for rttulti-cased''Wells OR LINER if a licable
AIR DRILLING INC s,+• ti' C`3�` `''4 FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft 140 ft- 6 in, GALV
276443 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.UIC,Canty,State,Variance•etc.) fL ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17,SCREEN
FROM To DIAMETER SLOTSIZE TIIICKNFSS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single)
ft. fL in.
❑industrial/Commercial ❑Residential Water Supply(shared)
18.GROUT
❑Irri ation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. GROUT POURED
❑Monitoring ❑Recovery ft• ft
injection Well:
❑A uifer Recharge ❑Groundwater Remediation ft. L
❑Aquifer Storage and Recovery ❑Salini Barrier 19.SAND/GRAVEL PACK if a licable
ty FROM TO I MATERIAL I EMPLACEMENTMETHOD
❑Aquifer Test ❑StormwaterDrainage ft. fL
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additionaLsheets if necessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soilhmck type rain sae,etc.
0 rL 40 ft. DIRT '
4.Date Well(s)Completed: 11-5-2021 well iD# 40 fL 405 ft- ROCK
So.Well Location: ft. ft•
LEBANON EVANGELICAL CHURCH fL ft.
Facility/Owner Name Facility iD9(if applicable) ft ft.
1200 THOMPSON RD,CLEVELAND,N.C. 27013 ft. ft.
Physical Address,City,and Zip ft. ft.
ROWAN 8200090001 21.REMARKS
County Parcel Identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: f
(ifwell field,one lat/Iong is sufficient) i� �r
��Ce fication•
35° 44.288 N 80037.348 W '"`` .,� _ __--
.. 11/5/2021
6.Is(are)the well(s): ItPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the irell(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
Ifthis is a repair•fill out known svell 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 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 i GW-1 is needed. Indicate TOTAL NUMBER ofwells (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
Tar multiple wells list a!1 depths ifdi(Jerent(example-3 ,200'and 1@100') (ft.) Submit this GW-i within 30 days of well completion per the following:
10.Static water level below top of casing: 50 (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
lfwater level it above casing,use"+" Information Processing Unit, 16,1 MSC,Raleigh,NC 27699-1617
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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: f
(i.e.auger,rotary,cable,direct push,etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
county environmentalhealth department of a county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells Droducine over 100.000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) 8 Method of test: AIR Permit Program,161 I MSC,Raleigh,NC 27699-1 61 1
13b.Disinfection type: HTH Amount:
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources i Revised 6-6-2018
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