GW1-2022-01580_Well Construction - GW1_20220120

I
WELL CONSTRUCTION RECORD(GW 1)
For Internal Use Only: r
L Well Contractor Information:
CHAD HARTNESS
14t.WATER ZONES
Well Contractor Name .�'';,t u r°--"' =FROMTODESCRIPTION
2901A J a 0�
NC Well Contactor Certification.Number
AIR DRILLING INC ;'4 rn dS:OUTER`CASING for'muldcased�Gens OR LINER ifa licable
i �FROM TO DIAMETER
li+.vs!.� -j rl THICKNESS MATERIAL
Company Name t 71 ft 6 in• GALV
235545 RCASINGORTUBING' eotttecmafclosea-loop)_
_2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits 0.e.UIC,County,State, Variance,etc.) ft ft. in.
3.Well Use(check well use): ft ft.
Water apply Well: 17.SCREEN
❑Agricultural FROM TO DIAMETER, SLOT SIZE THICKNESS MATERIAL
OMunicipal/Public ft. ft. in.'
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single)
ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared)
1S:GROUT
❑hri atlon ❑Wells>100000GPD FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0 IL 20 fL GROUT POURED
DMonitoring ❑Recovery fr ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation ft. ft
' • "` "
❑Aquifer Storage and Recovery OSalinity Barrier 19:SANDIGRAVEL'PACK ifalicableFROM 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)
❑Geothermal(Heating/Cooling Return) OOther(explain under#21 Remarks) FROM To DESCRIPTION color,hardness,soil/rock a rain size etc.
0 fL 61 ft. DIRT
4.Date Well(s)Completed: 11-24-2021 Well ID# 61 ft- 325 It- ROCK
5a.Well Location: tL ft.
TREXLER CONST ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1005 GREENHEATHER DR SALISBURY,N.0 28147 & ft.
Physical Address,City,and Zip ft. fL
ROWAN 473AO21 zl:REINARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: or
(if well field,one lat/long is sufficient) Cer anon:
35a 37.594 N 800 34.281 , -
W J `' 11/24/2021
6.Is(are)the well(s): Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certtry that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo ISA NCAC 01C.0100 or ISA NCAC 01C.0100 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 921 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: 325 (ft.
For multiple wells list all depths ifdierenr(example-3@200'and 2@100')' Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 10 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+^ Information Processing Unit,1617 MSC;Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
.Well construction method:
(i.e.auger,rotary,cable,direct push etc.) 24c.For Water Supely and O en-Lo i op Geothermal Return Wells:Copy to the
county environments th hea department of a county where insta
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,161] 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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