GW1-2022-01729_Well Construction - GW1_20220207

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information.-
Chad Hartness 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 0 ft. 190 ft, —0-
2901 A 190 ft, 245 ft- 20 GPM
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a Ileable
Hickory Well Drilling Co. , Inc. FROM TO DIAMFTFR I I THICKNESS I MATERIAL
0 ft, 127 f° 6 In' SR211 PVC
Company Name 16.INNER CASING OR TUBING eathormal closed•loo
2.Well Construction Permit#: WELL-10-2021-158984 FROM TO DIAMETER THICKNESS MATERIAL
in,
List all applicable well construction permits(1.a.UIC.,Cuunry,Slate,Variance,err.)
ft. ft.
ft, fY. in.
3.Well Use(check well use):
17,SCREEN
INon-Water
er Supply Well: PROW TO DIAMAAL
gricultural Municipal/Public c R.eothermal(Heating/Cooling Supply) Residential Water Supply(single) g g in.
dustrial/Commercial ®IResiderttiaJ Water Supply(shared) 18,GROUT
rl ation FROM TO MATERIAL EMPLACEMENT MF,THOD&AMOUNT
Supply Well: 0 ft. 20 Bentonite Poured
onitoring MRocovery ft.ction Well:quifer Recharge Groundwater Remediation19.SAND/GRAVEL PACK if a licable
quifer'Storage and Recovery OSalinity Barrier mom TO MATERIAL EMPLACEMENT METHOD
quifer Test oStormwater Drainage ft.xperimental Technology Subsidence Controleothennal(Closed Loop) Tracer 20.DRILLING LOG attach addldonal sheets if necessTO DESCRIPTION color hardnen coiUrock a Ain slap otc.eothermal (Heating/Cooling Return) nOther(explain under#21 Remarks) 0 ft. 120 ft- Dirt, Clay. Loose Rock
4.Date Well(s)Completed:0 1/2 1/2 0 2 2 Well ID# 120 fc 245 ft, Granite Bed Rock
ft. ft. 4r p 6
5a.Well Location: -
ft. ft.
Trans Ash, Inc. rc, ft• 4 ® 2
Facility/Owner Name Facility ID#(if applicable)
3085 Steam Plant Rd. , Sherrills Ford, NC n, ft,
tO
Physical Address,City,and Zip 28673 �.
461803123267 ft.REMARKS
Catawba ��',,,.
County Parcel Identification No.(PIN)
5b,Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22. Nti catlon-
35.6062032 N —80.9796543 02/02/2022
6.Is(are)the well(s) crmanent or ®ITemporary
Signature of Certified Well Contractor Date
By signing this form,1 hereby certJ6-that the KrU(s)was(were)constructed in accordance
7.Is this a repair to an existing well: MYes otXf3No with 15A NCAC 02C.0100 or 1SA NCAC 02C.0200 Well ConsIr"clian Standards and that a
11this/.v a repair,fill oul known well construction Igl'brmation and explain the nature of the copy a/'this record has been provided to the iti'el/owner.
repair tinder 42l remarks section or on the back of'this farm. 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 site details or well
construction,only 1 GW-1 is needed. Indicate_T,QTALNUMBER of wells
construction details. You may also attach additional pages if necessary,
drilled: D TN
H� SUBMITTAL 1NSTRUCTTONS
9.Total well depth below land surface: 245 00 24a, For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3(a3200'and 2@1100') construction to the following:
1o.Static water level below top of casing: 40 (ft.) Division of Water Resources,Information Processing Unit,
If wester level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
Rotary Air Drilled above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i,e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 20 Method of test Ay Air Test 24c.For Water Suualy&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfeedon type:Chl. Grans. Amount: 9 02 s. (7 5 70) completion of well construction to the county health department of the county
where constructed.
Form GW-1
North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016