GW1-2022-01812_Well Construction - GW1_20220120

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: �.
CHAD HARTNESS 'S 14:WATER zoNEs
Well Contractor Name a R"- FROM To I DESCRIPTION
2901 A 12 2 ? 389 ft- 390 rt.
Q
ft.
NC Well Contractor Cert ft.ification Number 1�;,(
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IS.-OUTER CASING for multi-cased wells OR LINER if a licablc
AIR DRILLING INC {a(i:yt,':�i�111 s �^ ;;0� FROM TO DIAMETER TIIICKNESS MATERIAL
gy�12,�.x...0 0 rt. 106 fL 6 in. GALV
Company Name
AP-311565 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER TIIICKNESS I MATERIAL
List all applicable ivell construction permits(i.e.UIC,County,State,Variance,etc) ft. ft. in.
3.Well Use(check well use): tt. tt. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl atlon ❑Wel Is>100,000 GPD FROM TO MATERIAL, EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 tt. 20 ft- GROUT POURED
❑Monitoring ❑Recovery it. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO I MATERIAL I EMPLACEMENT METlIOD
❑Aquifer Test OStormwater Drainage ft. rt.
❑Experimental Technology ❑Subsidence Control ft. I ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) FROM TO DESCRIPTION color,knrdness,soil/rock type,gmin sin,etc.
0 tt. 96 R. DIRT
4.Date Well(s)Completed: 8-17-2021 well ID# 96 rL 405 rt. ROCK
59.Well Location:
rt. rt.
JEFF GIBSON
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
214 ROWAN RD CLEVELAND,N.C. 27013
Physical Address,City,and Zip fit. ft.
IREDELL 4771591472 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal.degrees:
(ifwell field,one lat/long is sufficient) Werri ion. "'-
35° 42.571 800 45.541 �° ►---N w 8/17/2021
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
Ry.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 InNo 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction ittforination and explain the nature of the ojthis record has been provided to the well owner.
repair under 1121 remarks section or on the back of this form.
23.Site diagram or additional wcllldetails:
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-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: 405 (fit.)
Ear uwhiple wells list all depths iftifferent(example-3 a200'and 2 rr 100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 40 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
IJtrater level is above casing,use"t" Information Processing Unit, 1617 MSC,Raleigh,INC 27699-1617
11.Borehole diameter: 6 (in.) 24b. For Infection Wells: Copy to IDWR, Underground Injection Control (IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24c.For Water Supply and Open-Loon Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) 80 Method of test: AIR
Permit Program,1611 MSC,Raleigh,NC 27699-161 1
13b.Disinfection type: HTH3 Amount: I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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