GW1-2022-01572_Well Construction - GW1_20220120

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: l
CHAD HARTNESS
^','�'�d 14.WATER ZONES a
Well Contractor Name s:� ,� ��;, ,�"n a FROM TO DESCRIPTION
�> 5 209 ft. 210 ft.
2901 A "^ 2 ft. ft. 1
tP
NC Well Contractor Certification Number ! e
� 15.OUTER CASING for mul ed wells OR LINER if a licable
AIR DRILLING INC ;,..,,re;M.
tir� FROM I TO D(AM ETER I THICKNESS MATERIAL
Company Name + . `"� nr;E; s
0 ft 90 ft. 6 PVC
P y �'t ' w 16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: 317592 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable it construction permits(i.e.UIC,County,Stale, Variance,etc.) ft ft. 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/Com mere ial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 it• GROUT POURED
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation i
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,soiUrock type,grain size,etc.)
0 It. 80 ft. DIRT
4.Date Well(s)Completed: 7-7-2021 well ID# 80 ft. 225 ft. ROCK
5a.Well Location: fL ft.
TREXLER CONSTRUCTION ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
670 AUTUMN IGHT DR, SALISBURY,N.C. 28147 ft ft.
Physical Address,City,and Zip ft. ft.
ROWAN 458H008 21.REMARKS
County Parcel Identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one]at/long is sufficient) arlirIc
n: i
350 40.212 N 800 33.210 W
7/7/2021
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,i hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or In No 15A NCAC 01C.0100 or 15A NCAC 01C.p200 Well Construction Standards and that a copy
if this is a repair,fill out known well construction information and explain the native of die 2l 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-I 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: 225 (ft)
For multiple wells list all depths ifdierent(example-3r_&300'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
30 24a. For All Wells: Original formll 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"-
I1.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,ofthe county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 50 Method of test: AIR
Permit Program,1611 MSC,Raleigh,,NC 27699-1611
13b.Disinfection type: HTH Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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