GW1-2022-05415_Well Construction - GW1_20220311

Fi Id.IQLAUForm
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Informations
Chad Hartness 14,WATER ZONE9
FROM TO DESCRIPTION
Well Contractor Name 0 f. 100 fit. -0-
2901 A
100 f`' 185 f`' 100
GPM-
NC Well Contractor Certification Number 15.OUTER CASING for multi-eased wells OR LINER if a licable
HickoryWell Drilling Co. Inc. FROM TO DIANIFUR 'THICKNESS MATERIAL
g 0 fit. 37 fit• 6 1 4 in. I SR211 PVC
Company Name 16,INNER CASING OR TUBING(geothermal closed-10o
2.Well Construction Permit#: Burke Co. GI S 30723 FROM I TO DIAMETER THICKNF.aS MATERIAL
List all applicable well construction permits 0.a.U/C.•County,State,Variance,etc.)
ft. ft. in.
ft. fit. 1n.
3.Well Use(check well use):
17,SCREEN
Water Supply Well: ni
TO DIAMETER SLO•f SIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. in.
Geothermal(Heating/Cooling Supply) )OResidential Water Supply(single) ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrl ation FROM ITO MATERIAL EMPLACEMENT MF,THOD&AMOUNT
Non-Water Supply Well: 0 ft' 20 f' Bentonite Po red from-Ton
Monitoring ORccovery fit, ft.
Injection Well: ft. ft.
Aquifer Recharge oGroundwater Remediation 19.SAND/GRAVEL PACK df a ilcablo
Aquifer Storage and Recovery EISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test EIStommwater Drainage fL fe.
Experimcntal Technology E3Subsidence Control ft. fit.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional-sheets if necess
FROM I TO DESCRIPTION color hardness solUrack tyaq.arRin size etc.
Geothermal (Heating/Cooling Return) .Other(explain under#21 Remarks) 0 ft' 10 ft* Dirt Loose
gork
4.Date Well(s)Completed:02/11/2022 wall ID# 10 ft- 185 ft, Granite Bed Rock
ft. ft,
5a.Well Location:
ft. fit.
Lloyd Anderson
ft.
Facility/Owner Name FacilityIDii(ifa PPlicable) ft.
ft. ft.
3905 Brittain St. , Hickory, NC 28602
fit. rt.
Physical Address,City,and'Lip
21.REMARKS
Burke
1
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattiong is sufficient) 22.Certification:
35.706380 N 81.434827 w /08/2022
6.Is(are)the well(sPcrmanent or ®ITemporary
Sign of rtificd Well Contractor Date
By signing thdr form,I hereby certlh•that the Nr//(s)was(were)constructed in accordance
7.is this a repair to an existing well: OYes orX[3No with/SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Consttltction Standards and that a
Ifthis is a repair,fill oul known well construction lnjtrination and explain the nature of fhe copy nl7his record has been provided to ilia well owner.
repair under#21 retnarks section at-on the back of this fibrin. 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 S_UBMiTTAL INSTRUCTIONS
9.Total well depth below land surface: 185 (fit•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2rg100') construction to the following:
1o.Static water level below top of casing! 20 (ft.) Division of Water Resources,Information Processing Unit,
1f inter level is above casing,use"+•' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in,) 24b.For Infection Wells: In addition to sending the form to tie address in 24a
Rotas Air Drilled above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: Y construction to the following:
(i,c,anger,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) 100 Method of test:By Air Test 24c.For Water Supply&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: 7 OZ s(7 5%) 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