GW1-2023-00384_Well Construction - GW1_20230103

WELL CONSTRUCTION RECORD (GW I) For Internal Use Only:
I.Well Contractor Information: I
CHAD HARTNESS
-'14.WATER ZONES' -
Well Commctor Name FROM •ro DESCRIPTION
2901 A 409 rc• 410 ft. 0 1
ft. ft. I
NC Well Contactor Certification Number E I
!1 � M
ulti-cased.wells OR'LINER^(if a licableAIR DRILLING INC DIAMETER 1 THICKNESS MATERIAL
Company Name6 li.317577 UBING etithcrmal closed-too2.Well Construction Permit#: DIAMETERList all applicable well constniction permits(i.e.U1C,County,State, Variance,:etc•.)3.Well Use(check well use): in.
Water Supply Well: 17iSCREEN
FROAI TO DIAM P:I-ER I SLO'r SIZE I-'I'111CKNE55 I MATERIAL
❑Agricultural ❑Municipal/Public tt. R. in.
❑Geothermal(Heating/Cooling Supply) InResidential Water Supply(single)
ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
18.-GROUT
❑Irri ation ❑WCIIS>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 rc• 20 f' GROUT POURED
❑Monitoring ❑Recovery ft. ft.
Injection Well:
❑A uifer Recharge ❑Groundwater Remediation ft. ft.
❑Aquifer Storage and Recovery = ❑Salinit Barrier '19.'SAND/GRAVEL'PACK if a acabie
y FRO\I TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stonnwatcr Drainage
❑I xperimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additi6nal'she6ts if necessar'
❑Geother mal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION(color•hardness,soil/rock type,grain sire,etc.)-
0 63 f'• DIRT
4.Date Well(s)Completed: 07-25-2022 Hell ID# 63 rc• 425 ft- ROCK
5a.Well Location:
LAKEMIST HOMES
PaCilily/Owner Name Facility ID#(irapplicable) -
[' r' r
115 RYLEIGH DAN,MOORESVILLE,N.C. 28117
Physical Address,City,and Lip ft. ft. j13A
IREDELL 4654687228 r �
•IL'REMARKS
County Parcel identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
2.C tifica bn:
35° 31.072 N 80° 49.505
W -7/25/2022
6.Is(are)the well(s): InPermanent or ❑Temporary Signature orCertified Well Contractor Date
By signing this form,1 hereby cent fv that the ivell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or [!]No 15A NCAC 02C.0100 or 15.4 NCAC 02C.0200 iVell Construction Standards and that«copy
1f this is a repair,,fll out known well construction info•nnalion and explain the nature of the of this record has been provided to the we/1(I wner.
repair under 921 remarks section ar on the back of this fora. i I
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 construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'Scc Ovcr'in Remarks Box).You may also attach additional pages if necessary.
drilled:
24.SUBMITTAL INSTRUCTIONS
9.'Total well depth below land surface: 425 (ft.)
For multiple wells list all depths/fdifferent(avample-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 50 (ft) 24a. For All Wells: Original form Ito Division of Water Resources (DWR),
lfhvater level is above casing,use"+ Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in,) 24b.For Injection Wells: Copy to DWR, Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
i..Well construction cable, method: 24c.For Water Su ly and Open-LoonGeothermal Return Wells;Copy to the'
(i.e.auger,rotary,cable,direct push,etc.) county envvonmenta�health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing ovcl 100,000 GPD• Copy to DWR,CCPCUA
13a.Yield(gpm) 12 Method of test-AI R Permit Program,1611 MSC,Raleigh,NC 27699-16I 1
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13b.Disinfection type: H.TH Amount
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources 1 ( Revised 6-6-2018