GW1-2022-01575_Well Construction - GW1_20220120

I
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: / ?�
CHAD HARTNESS \•way'
\'*,j° 14.WATER ZONES
-
Well Contractor Name ��a,`v r• FROM TO DESCRIPTION
2901A _r ' �' tiC�� .r r,: 329 ft 330 ft.
o . :. ft. ft.
NC Well Contractor Certification Number ry
n C 15.OUTER CASING for mu1N-eased wells OR LINER if a licable
AIR DRILLING INC r �\ 't y;jl` FROM TO DIAMETER THICKNESS MATERIAL
0 ft 79 ft. 6 'in: PVC
Company Name
246822 v 16.INNER CASING OR TUBING eotherinal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS 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.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑1rri 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 applicable),
❑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 addifional'sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain sae,etc.
0 fL 69 ft. DIRT
4.Date Well(s)Completed: 5-21-2021 Well iD# 69 ft• 345 ft- ROCK
5a.Well Location: ft ft.
BRAD BOLING ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1490 AGNER RD, SALISBURY,N.C. 28146 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 ha/long is sufficient) 22. of on:
35a 36.276 N 800 20.340 W
6.Is(are)the well(s): InPermanent or ❑Temporary Signature of Certified Well Connector Date
By signing this form,!hereby certify that the,well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 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 s!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 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: 345 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths it different(example-3@200'and 2@1 00')
10.Static water level below top of casing: 60 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
!f water level is above casing,use" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
I I.Borehole diameter: 6 (in,) 24b. For Injection Wells: Copy to D,WR,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
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) 15 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