GW1-2022-06535_Well Construction - GW1_20220503

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
Chad Hartness 14.WATER ZONE
S
FROM TO DESCRIPTION
Well Contractor Name 0 ft- 250 ft- .5 GPM
2901 A 250 ft. 305 ft- 2.5 GPM
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a llcable
FROM TO DIAMETER '; 'THICKNESS I MATERIAL
Hickory Well Drilling Co. , Inc. 0 ft. 68 ft. 6 1/4'In. SR211 TPvc
Company Name 16.INNER CASING OR TUBING cothcrmal closed-loop)
2.Well Construction Permit#: Caldwell #891 FROM TO DIAMETER I TFIICKNF.SS MATERIAL
List all applicable well construction permits(I.e.UIC,County,Slate,Variance,eir.)
ft. I ft. In.
ft. ft. in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSI2E THICKNESS MATERIAL
f"tAgricultural Municipal/Public a ft. ft. In.
In
eothennal(Heating/Cooling Supply) XoResidential Water Supply(single) ft. ft. In.
dustrial/Commercial ®IResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
-Water Supply Well: 0 ft, 20 ft• Bentonit Poured fromTon -
onitoring ORecovery ft ff•
ction Well: ft. ft.
quifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK if a Monte
quifer Storage and Recovery [3ISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
quifer Test DStormwater Drainage ft. t't.
xperimental Technology Subsidence Control
eothennal(Closed Loop) �ITracer 20.DRILLING LOG attach additional sheets if necessaFROM TO DESCRIPTION color hnnlnesr solUeothermal(Heating/Co lin Return) nOther(explain under#21 Remarks) 0 tt, 60 ft. Dirt Loose ROC
4.Date Well(s)Completed. 04/25/2022We111D# 60 ft- 305 f" Granite Bed Roc
ft ft,
5a.Well Location:
ft. ft.
Ed Wootton
Facility/Owner Name Facility iD#(if applicable) ft. ft.
•--
1200 Cottrell Hill Rd. , Lenoir, NC 28645 ft' ft.
ft. ft.
Physical Address,City,and Zip
Caldwell 2851807497 21.REMARKS
County
Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one laUlong is sufficient) rtifiea n:
35.95121 N 81.50449 W ,04/29/2022
6.Is(are)the well(s) ermanent or E3'[emporary
Signature of Certified Well Contractor Date
By signing this form,1 hereby certifi,•that the xrll(s)was(were)constructed In accordance
7.is this a repair to an existing well: E)Yes oxJ3No with iSA NCAC 02C,0100 or I SA NCAC 02C.0200 Well Construction Standards and that a
.if this Ls a repair,fill out known well construction inf n•unation and explain the nature q/'the copy gl7his record has been provided to the,well owner.
repair under#21 remarks section or on the back gfthlsform. 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 yVAI is needed. Indicate TOTAL NUMBER of wells
construction details. You may also attach additional pages if necessary.
drilled: / SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 305 -(ft-) 24a. For All Wells: Submit t1iis form within 30 days of completion of well
For multiple welly list all depths if e4fler•ent(example-3Ca3200'and 2(tW 00') construction to the following:
lo.Static water level below top of casing: 60 (ft.) Division of Water Resources,Information Processing Unit,
If rarer level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
Rota 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:
(ix,sugar,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) 3 Method of test:By Air Test 24c.For Water Suaaly&Iniection Wells: In addition to sending the forth to
the address(es) above, also submit;oue copy of this form within 30 days of
13b.Disinfectiontype: Chl. Grans. Amount: 10 OZs. (75%) completion of well construction to the county health department of the county
where constructed,
Forth GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016