GW1-2021-02678_Well Construction - GW1_20210930

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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
2901 A 0 rt. 325 ft' 2 GPM
325 ft. 485 ft. 10 GPM
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells 0 1 LINER If a licable
Hickory Well Drilling Co. , Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 53 f' 6 1 m.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: WELL-04-2021-149054 FROM I TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e. UIC,Count);,State,Variance,etc.) ft. ft. in,
3.Well Use(check well use): ft.17.SC
Water Supply Well: FROM REE TO DIAMETER' SLOT SIZE THICKNESS-1 MATERIAL
Agricultural Municipal/Public 0 ft. ft. in,
Geothermal(Heating/Cooling Supply)xiBResidential Water Supply(single) ft. ft. in.
]ndustriaVCommercial OResidcntial Water Supply(shared) 18.GROUT
Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 It- 20 tt' Bent6nite Poured
Monitoring E3Rccovcry ft. ft.
Injection Well: ft. ft.
Aquifer Recharge [3Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ®IStormwater Drainage ft. ft.
Experimental Technology MSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20,DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness soiUroek sin size,etc.
Geothermal Hearin Coolin Return) Other(ex lain under#21 Remarks)
0 rt' 45 rt' Dirt Clay
4.Date Well(s)Completed:08/20/2021 Well ID# 45 ft 485 fL Granite Bed Rock
5a.Well Location: ft. ft.
Ct. tt.
Steve Hansen
Facility/Owner Name Facility iD#(if applicable) ft. ft. O 2
6335 Huntington Lane, Conover, N. C.28613 rt. ft, iili
Physical Address,City,and'Lip ft. ft. 'n$Oi(„ati0il ipll
Catawba 374501169087 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) C rtifFea
35.769426 N 81.200954 W Vvn�9/28/2021
6.Is(are)the well(s)opermanent or Temporary Signature of Certified Well Contractor Date
By.signing this form,i hereby certifi•that the welift)was(were)constructed in accordance
7.is this a repair to an existing well: [3Yes or ONo with 1 SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction Information and explain the nature of the copy of this record has been provided to the well aivner.
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only) 1 -1 is needed. Indicate TOTAL NUMBER of wells
construction details. You may also attach additional pages if necessary.
drilled: H SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 485 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdigerent(example-3@200'and 2(g100') construction to the following:
10.Static water level below top of casing: 100 (ft.) Division of Water Resources,Information Processing Unit,
1f water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
il.Borehole diameter: 6 (in,) 24b.For Injection Wells: In addition to sending the form to the address in 24a
ROtaY 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
r,
13a.Yield(gpm) 12 Method of test: By Air Test 24c.For Water Sunaly&Injection Wells: In addition to sending the form to
Chl. Gratis. 16 Oz s. (75�� the address(es) above, also submit one copy of this form within 30 days of13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016