GW1-2021-02666_Well Construction - GW1_20210805

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Chad Hartness 14.WATERZONES
Well Contractor Name FROM TO I DESCRIPTION €
2901 A 0 f`' 380 f` Trace
NCWeIIContractorCertificationNumber 380 f`' 425 f`' 5 GPM
15.OUTER C for multi-cased wells UR LINER if a Ilcable
Hickory Well Drilling Co. , Inc. FROM Vol' DIAMETER THICKNESS MATERIAL
Company Name 0 ft' 63 ft. 6 1 4ln' .185 IGalv. Stec
GI S 3 7162 16.INNER CASING OR TUBING''. eothermat closed-loo
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction perinits(i.e.UiC,C(nnnry•,State, Varianr e,etc.) ft. ft. in,
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SiZE THICKNESS MATERIAL
Agricultural Municipal/Public 0 ft. ft. in.
is
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 1
18,GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft, 20 fL Bentonite Poured from To
Monitoring ORccovery
Injection Well:
ft. ft.
Aquifer Recharge Io'Groundwater Remediation
Aquifer Storage and Recover 19.SAND/GRAVEL PACK if a licable
q g Y C3SalinityBarrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft• ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) C)Tracer 20.DRILLING LOG attach additional sheets if necessar
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soil/rock rain size cte,
0 ft• 55 ft' Dirt, Loose Rock, Clay
4.Date Well(s)Completedp7/22/2021 Well ID# 55 "' 425 f`' Granite Bed Rock
5a.Well Location: ft. ft.
Zeb Trinity
Facility/Owner Name Facility ID#(ifapplicuble) ft. ft.
6122 Dysartsville Rd. , Morganton, NC 28655 ft. ft. MA
Physical Address,City,and Zip tt. ft. Ina"tit
Burke 21.REMARKS g
County Parcel Identification No.(PIN) 3�ro� Qt1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient)
t vtiricatl
35.640892 N 81.837455 W 7/29/2021
6.Is(are)the well(s)oPermanent or OTemporary Signature of Certified Well Contractor Date
By.rigging this fornn,1 hereby certift•that the a•ell(s)was(were)constructed in accordance
7.is this a repair to an existing well: ®IYes or No with ISA NCAC 02C,0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,•fll oat known well construction information and explain the nature afthe copy q/7his record has been provided to the well owner. `
repair under 421 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 site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: N/A SUBMITTAL INSTRUCTIONS'
9.Total well depth below land surface: 425 24a. For All Wells: Submit this form within 30 days of completion of well
For nmltiple wells list all depths ifeliQerent(example-3(a3.00'and-@&100') C0115t1uCti01)t0 the following:
Ifi Static water level below top of casing: 2 (ft.) Division of Water Resources,Information Processing Unit,
If nester love!is above casing,use"+" 1617 Mail Service tenter,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in,)
24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: Rotary Air Drilled above, also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) Construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a,Yield(gpm) 5 Method of test: By Air Test 24c.For Water Supply&Injection Wells: In addition to sending the form to
Chl. Grans, 16 OZS. (]5�) the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed. i
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources? Revised 2.22-2016