GW1-2023-00403_Well Construction - GW1_20230103

WELL CONSTRUCTION RECORD (GN1,1-1) T(�j�Internal Use Only:
1.Well Contractor Information:
CHAD HARTNESS
14.WAWR ZONES
Well Contractor Name FROM .1.0 DESCRIPIrION
1,?69 ft-fO ff-
2901A
NC Well Contractor Certification Number
15.0 11TER CASING(for multi-casedlw2fls)o-U LMa iIlL e ,AIR DRILLING INC TO IDIAMETEV ' MV.. L_0 102 1
Company Name 6 ; PVC J
i 16.INNER CASING OR TUBING(a6thermal closed-l6op):--'. '-- J
2.Well Construction Permi I it; 319055 1 .1.0 DIAMETER THICKNESS I MATERIAL
List all applicable ivell construclimi permits(i.e.01C,Cotim.l.Sijl we,vic.) ft. in.
3.Well Use(check well use): in.
Water Supply Well: 17.SCREEN
TO SLOTSIZE THICKNESS MATERI 1,
CAgricultural IAM Lill ic if):]; 11t1hlic II ff. in.:
i
DGeothermal(Heating/Cooling Supply) I'lRo.Nidomial W;acr SuppIN,(silipl,.I
in:
0[ndustrial/Commercial 1-111csid"Illial Walcl.Supply
DIrrigation (sharcd)
1 1 Wel Is 100,000(.;Pl) TO 51ATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water'Supply Well: 0
1` 20 , ft- GROUT POURED
DMonitoring
Injection Well:
OAquifer Recharge
11).SA N D/G RAVEL PACK(if arinfitiable)
[]Aquifer Storage and Recovery Hsalinitv Ilarricl.
I?Lim TO MATERIAL EMPLACEMENT METHOD
DAquifer Test I'Istorlliwnwr I)I;IiII;IPC ft.
DExpe Technology rimental
ft.
DGeothermal(Closed Loop) I ITI-accl.
20.DRILLING LOG(attach additionalsheets ifhecessary)�,
013cothcrmal(Heating/Cooliji,Return) I 10111cr(C.x1flain Illider fl.".I Rcllmd��) —'ro DESCRIPTION(color,hardness,soil rock type,gnin size,etc.)
92 Q I RT
4.Date Well(s)Completed: 5-4-2022 1%;vql I I)q
92 285 ROCK
5a.Well Location:
SPIVEY CONSTRUCTION
Facility/Owncr Name Facilil ifnpplicahle)
124 CHASESTONE LANE,MOO RESVI LLF,N.C. 28117 01 L)J
Physical Address,City,and Zip ft.
IREDELL 4614-827630
County Parvol 1,,:niillwaiion No.(111N)
5b.Latitude and longitude in degrees/iiiiiiiiies/.gt!(.I)11(ls or dveinull degrees:
(ifwcll field,one iat/long is sufflicient)'
35029.593 80- 57.11 -1 r
N 7
/4/2022
6.Is(are)-the well(s): M Ile rni.,,nent or rri-empoi.:lry `ihtnillto'e of'Certificd Well Contractor Date
1f­h:nhk­thisfin-in,1herehy c-crti/i,that th ivell(s),was(were)constructed in accordance with
7.Is this a repair to an existing well: I- esIli- ';N(I /.,.-I.W.ICO2C.0J00 or 1511,VdACO2C'0200 Well Construction Standards and that a copy
Ifthis is a repair,f!11 out known well collsirlictif",infin-111,11i­; -.+pl,im ih,-nalurr ,I*i,:,,
repair(eider#21 remarks section or on the back qf Ibis;form.
23.Sill-diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geolliernlid \Vtlls III,! YOU 11my use the back or this page to.Provide additional well construction info
construction,only I GW-I is needed. IndicaloTOTA I.`,'1".\.I Ifl-A..id'wclls (;idd'Scc Over'in Remarks Box).Yodmay also attach additional pages ifncccssary.
drilled.
s I;iI.)I irrAL INSTRUCTIONS
9.Total well depth below fall(I surface: 285
--ibmit (his GW-I within30-days of well completion per the following:
For inultiple ivells list all depths�fdijfereni(em 1,1,�
10.Static water level below top of casing: 40 For All Wells: Original.forn-i I,to Division of Water Resources (DWR),
Iftvater level is above casing,tesf, 11 I'ornlzil ioll Processing Unit, 1617 Mk,Raleigh,NC 27699-1617
11.Borehole diameter: 6
2-111. VOK Illieclion Wells: Copy to DWR, Underground Injection Control(IUC)
u1 rum. 1636 MSC,Raleigh,NC 2*94636
12.Well construction method:
(i.e.auger,rotary,cable,direct posh,etc.) ..-Ic.I-`nr lValler Supply and Open-Loop.Geothermal Return Wells:Copy to the
:,ILI I I[.\,ell Viroillmental health departnidlit'of the county where installed
FOR WATER SUPPLY WELLS ONLY:
.1d. For Water Wells produchuz over'100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(go-) 15 A!Mel hod of'lesl: R rani, 1611 MSC,Raleigh, C
13b.Disinfection type: HTH
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Form OW-1 ,d'I:uc:+,urr':; Di\,ision ol'WiLlcrResources Revised 6.6-2018