GW1-2023-00506_Well Construction - GW1_20230104

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: I
1.Well Contractor Information: i
CHAD HARTNESS
14.WATER ZONES. I I
Wcll Contractor Name FROM 1'O DESCRIPTION
2901 A 129 ft. 130 ft.
NC Well Contractor Certification Number
IS.OUTER CASING(for multi-cased,wells)OR LINER(if a able
AIR DRILLING I N C )
FROM TO lica
DIAMETER; TIIICKNESS MATERIAL
Company Name
062 ft. ft. 6 ' i PVC
367377 16.INNER CASING OR TUBING ebtllermal closed-too
2.Well Construction Permit#: FRO\I TO DIAMETER TIIICKNESS MATERIAL
List all applicable sell construction permits(i.e.U1C,Camay.State, I'ariance,etc.) ft. ft. in.
3.Well Use(check well use): fl. tt. in.
Water Supply Well: 17.SCREEN
FROM •11O DIAMETER 'SI.O'1•SI%E .'1'l I1CKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic ft. R. in.
❑Geothermal(Heating/Cooling Supply) [!Residential Water Supply(single) in.
❑Industrial/Commercial ❑Residential Water Supply(shared) i8.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD S AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. GROUT POURED
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remcdiation
❑Aquifer Storage and Recovery ❑SRlinit Barrier 19.SAND/GRAVEL PACK if applicable)
y f!�
TO MATERIAL EMPLACEMENTMF,TIIOD
❑AquifcrTest ❑StormwaterDrainage ft.
❑Experimental Technology ❑Subsidence Control tt. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soillrock type,gmin size,etc.
0 n. 52 rt. DIRT
4.Date Well(s)Completed: 08-03-2022 Well ID# 52 f` 145 f` ROCK
Sa.Well Location: ft. ft.
TREXLER CONST ft. ff.
Facility/Owner Name Facility iDII(if applicable) ft. ft. 'Sun :i_fig
1206 OAKBLUFF, SALISBURY,N.C. 28147 ft. ft. JAN 0 4 ,
023
Physical Address,City,and Zip ft. ft.
ROWAN 458EO12 21.REMARKS -i:;:
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degreeshninutes/seconds or decimal degrees:
(ifwell field,one hit/long is sufficient)
350 40-351 N 80- 33.081 W
$/3/2022
6.Is(are)the well(s): Inflermanent or []Temporary Signature otCertiGed Well Contractor Date
1lvsigning this,%rm,l hereby certyJ that tle ivell(s)u•as(were)constructed in accordance frith
7.Is this a repair to an existing well: ❑Yes of IJNo 15A NCAC 02C.0100 a,.15A NCAC 02C.0200 Well Construction Standards and that a copy
!/'this•is a repair,fill our known Nell construction h Jorntation and explain the nature o/?he o/pthis record has been 1lrovltlet/to the❑e//oll'oe r,
repair under#21 rento•ks section or of the brick oj'this farm.
23.Site diagram of additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You nnay use the back of this page to provide additional well construction info
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells (add'Scc Over'in Remarks Box).You niay also attach additional pages ifnccessary.
drilled:
24.SUBMITTAL INSTRUCTIONS9.Total well depth below land surface: 145 ft
For nudtiple(reds list all depths ijdifJerrnt(crumple-3 n 200'and 2 a 100') ( ) Submit this GW-I within 30 days or well completion per the following:
10.Static water level below top of casing: 30 (ft*) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information]'recessing Unit, 1617 MSC,Ralei h,NC 27699-1617
!'water level is above casigs,use
g g
11.Borehole diameter: 6 (in•) 24b.For Injection Wells: Copy to,DWR, Underground Injection Control(1UC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: i
24a For Water Supply and Open-Lotip Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing;over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) 5 Method of lest:
AI R Pennil Program,1611 MSC,Raleigh,NC i 27699-1 6 1 1
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13b.Disinfection type: HTH Amount: ,
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018