GW1-2022-01574_Well Construction - GW1_20220120

WELL CONSTRUCTION RECORD(GW-1)��,, y For Internal Use Only:
1.Well Contractor Information:
CHAD HARTNESS � , �0�` f4489
4.WA�TEZONEs. .,. .. .
Well Contractor NameT ROMTO DESCRIPTION
`� ` 490 ft. `
2901 A
ft: tr.
NC Well Contractor Certification Number -
y. 15.'OUTER CASING for mul6-cased wells OR'LINER "hcable``_.
AIR DRILLING INC ,� '�' FROM TO DIAMETER TIICIINESS MATERIAL
0 ft- 85 ft- 6 in. GALV
Company Name
16.INNER CASING OR TUBING eotbermal closed-loo
2.Well Construction Permit#: 336254 FROM TO DIAMETER THICKNESS I MATERIAL.
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. M tin.
3.Well Use(check well use): ft ft. in.
17SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE,. THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public & ft. in.
❑Geothermal(Heating/Cooling Supply) InResidential Water Supply(single) fL M tn.
❑Industrial/Commercial ❑Residential Water Supply(shared) I&GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 fL GROUT POURED
❑Monitoring ❑Recovery f4 IL
Injection Well:
tt ft
❑Aquifer Recharge ❑Groundwater Remediation
19::SAND/GRAVEL PACK ifs 'licable ,
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft: fL
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets ifnecessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,Hardness soil/rockqpe,grainsae ere
0 f- 75 fL DIRT
4.Date Well(s)Completed: 2-26-2021 Well ID# 75 ft. 505 ft- ROCK
59.Well Location: fr fL
ROCKWELL FARMS It. fL
Facility/Owner Name Facility mh(if applicable) ft. ft.
310 ROCKWELL FARMS RD,SALISBURY,N.C. 28146 fL ft.
Physical Address,City,and Zip ft. ft.
ROWAN MAEMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 2. ertiric on:
35a 32.415 800 27.272
N w � - --- � '"2/26/2021
6.Is(are)the well(s): InPermanent 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.0200 Well Construction Standards and that a copy
1f 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Ovee in Remarks Box).You rhay also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 505 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if dierent(example-3@200'and 2@100')
10.Static water level below top of casing: 70 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
"
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use"+
11.Borehole diameter: 6 24b.For Injection Wells:Copy to DWR,Underground Injection Control(NC)
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
k
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm)
20 Method of test: AIR Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 6-6-2018
I