GW1-2022-01571_Well Construction - GW1_20220120

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: j
1.Well Contractor Information:
CHAD HARTNESS 14.WATER ZONES
Well Contractor Name O -L FROM TO DESCRIPTION
2901 A 289 ft. 290 ft i
r eeloq ft. ft
NC Well Contractor Certification Number %'' -;0
!'"rt`�3�sQ�tt"1 1 FROMUTERCTOSING form DIt ET�ERells OTHICYKIVESS a ItMA15. TERtAL
AIR DRILLING INC ��;''� ati� 0 ft 63 ft 6 in. I I PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER: THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State, Variance,etc) ft. ft.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
(llrri atlon ❑Wel ls>100,000 GPD FROM I 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 licablb
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. fa
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION.color,hardness,soil/rock e, rein size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#2l Remarks)
0 ft- 53 ft. DIRT
4.Date Well(s)Completed: 07-16-2021 well ID# 53 ft. 305 ft. ROCK
Sa.Well Location: ft. ft.
BOBBY WEISENBERGER ft. IL
Facility/Owner Name Facility iD#(ifapplicable) ft. ft.
10900 UNITY CHURCH RD,MOORESVILLE,N.C. 28115 ft. ft.
Physical Address,City,and Zip ft. ft.
ROWAN 21.REMARKS
County Parcel Identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one[at/long is sufficient) ertiton:
350 34.180 N 800 42.554 w
7/16/2021
6.Is(are)the well(s): InPermanent or ❑Temporary Signature of Certified well Connector Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or In No 15A NCAC 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 of this record has been provided to the well,owner.
repair under'21 remarks section or on the back of ihis.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: 305 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if dierent(example-3(:cP '100'and-@100')
30 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 27699-16I7
/f water level is 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) 80 Method of test: AIR Permit Program,1611 MSC,Raleigh,NC 27699-1611
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13b.Disinfection type: HTH Amount:
Form GW-I North Carolina Department ofEmironmental Quality-Division of Water Resources Revised 6-6-2018