GW1-2022-03051_Well Construction - GW1_20220303

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Chad Hartness 14.WATERZONE9
FROM TO DESCRIPTION
Well Contractor Name 0 ft• 365 1" —0-
2901 A 365 ft' 645 ft' 2 GPM
NC Well Contractor Certification Number 15.OUTER CASING for multi•cased wells OR LINER if ap licabie
Hickory Well Drilling Co. , Inc. FROM fR TO f. DIAMETER In. THICKNESS MATERIAL
0 7
Company Name 16.INNER CASING OR TUBING aotharmal closed-Too
2.Well COnstrnCHOnPermit#: GIS# 29264 Burke FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well eonstruciinn permits(I.e.UIC.,County•,Slate, Val-lance,010
ft. ft. In,
ft, R, in.
3.Well Use(check well use):
17.Sc
Water Supply Well: REEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public a ft. ft, In.
Geothermal(Heating/Cooling Supply) 1BResidential Water Supply(single) ft, ft, in. !.
Industrial/Commercial OResidential Water Supply(shared) F! GROUT
Irrigation
FROM TO MATERIAL EMPLACEMENT MF.TNOD&AMOCJNT
Non-Water Supply Well: 0 ft, 20 ft- Bentonite Poured from To
Monitoring ORccovcry It. ft.
Injection Well: ft. ft.
:)Aquifer Recharge (( Groundwater Remediation 19.SAND/GRAVEL PACK if a licablo
Aquifer Storage and Recovery �ISalillity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage fL ft.
Experimental Technology Subsidence Control
C,eothennal(Closed Loop) OTtacet 20.DRILLING LOC attach addlNonal sheets if neceasa
FROM TO DESCRIPTCON color hervinon coiUcoak a ruin siao ate.
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks) 0 ft- 50 ft. Dirt, !Loose Rock
4.Date weil(s)Completed: 02/07/2022We11ID# 50 ft' 645 ft' Granite Bed Rock
ft. ft.
5a.Well Location:
ft. tt.
Bill Barrett
ft• ft.
Facility 1D#(ifs
Facility/Owner Name tY PPlicable)
to
6820 Bradshaw Rd. , Hickory, NC 28602 fe, tt.
ft. ft. AR
Physical Address,City,and Zip
Burke 21.REMARKS
Di
County Parcel Identification No.(PIN) �•
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latilong is sufficient) 2 Cert[ Non:
35.65210 N 81.49618 W NV 02it28/2022
c r -W%F-— I
6.Is(are)the well(s) crmanent or ®I'femporary
Signature of Certified Well Contractor Date
By signing rhLs form,/hereby certh•that the we/l(s)was(acre)constructed In accordance
7.is this a repair to an existing well: ®(Yes or ONO with 15A NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Consiruction Standards and that a
{/'this is a repair,,Ql/ou/known well construction/gf rrmation and explain the nacre of the Copy(If this record has been provided in the well owner.
repair tinder,#21 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 I G /IA
Is needed. Indicate TOTAL NUMBER of wells
construction details. You may also attach additional pages If necessary.
drilled: 1V SSUBMiTTAL INSTRUCTIONS
9,Total well depth below land surface: 645 (ft.) 24a. For All Wells: Submit this forin within 30 days of completion of well
For multiple wells list all depths tf different(example-3(a)200'and 2(y100') construction to the following:
10.Static water level below top of casing: 50 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above Casing,use„+'• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in,) 24b.For lniection Wells: In addition to sending the form to the address in 248
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.sugar,rotary cable,direct push,etc.)
Division of Water Resources,Underground IltJectlon Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
i
13a.Yield(gpm) 2 Method of test: By Air Test 24c.For Water Suably&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.Disinfection type:Chl. Grans. Amount: 24 Ozs. (75%) 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