GW1-2022-01569_Well Construction - GW1_20220120

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: _
CHAD HARTNESS 'm
m4a'Z ` 14.WATER ZONES
Well Contractor Name
FROM TO -DESCRIPTION
2901 A 449 rt 450 ft
4'�tv� 6:
NC Well Contractor Certification Number ft ft.
fi f' 15:OUTER CASING for multi-eased wells OR LINER if a" licable
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AIR DRILLING INC 4�>�`'' t+r.Yt(5� FROM TO DIAMETER THICKNESS MATERIAL
0 ft- 181 ft. 6 in: PVC
Company Name \ii`• �j'ti
327616 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER' I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) ft ft. i in.
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17.SCREEN
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 ation ❑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 a licable _
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL'; EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft.
❑Experimental 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 TO DESCRIPTION color,hardness,soil/rock type,grain sae,etc
0 ft 71 ft. DIRT
4.Date Well(s)Completed: 8-4-2021 Well iD# 71 ft 465 ft- ROCK
Sa.Well Location:
ft ft.
COMPTON BUILDERS ft ft.
Facility/Owner Name Facility ID#(if applicable) ft ft.
440 CAL KENNEDY RD,CLEVELAND,N.C. 27013 ft ft.
Physical Address,City,and Zip ft ft.
ROWAN 277046 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) rtific n:
35° 43.295 N 80° 43.299 Wrz/ . ----- - - 8/4/2021
6.Is(are)the well(s): MPermanent or ❑Temporary Signature ofCenified Well Contractor Date
By signing this form,I hereby certify that the we11(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 01C.0200 Well Construction Standards and that a copy
t(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 411 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: 465 (ft) Submit this GW-1 within 30 days of well completion per the following:
for multiple wells list all depths indifferent(example-3@200'and 1@100')
40 24a. For AU Wells: Original form to Division of Water Resources (DWR),
/f
ff wafer level is above casing,use Static water level below top of casing: (ft.) Information Processing Unit,1617 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: 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: I
24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) 12 Method of test: AIR
Permit Program,1611 MSC,Raleigh,NIC 27699-161 I
13b.Disinfection type: HTH Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018