GW1-2023-00550_Well Construction - GW1_20230104

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WELL CONSTRUCTION RECORD (GW 1) For Internal Use Only:
I.Well Contractor Information:
CHAD HARTNESS 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2901 A 249 ft, 250 rt.
ft. ft.
NC Well Contactor Certification Number
15.OUTER CASING for multi-cased wells OR LINER Qf UP cable)
AIR DRILLING I N C
FROM TO DIAMETER TItICKNESS MATERIAL
rt. rt. hr.
Company Name 48 6 PVC
05-2022171225 16.INNER CASING OR TUBING( eothernial closed-loop)
2.WCII Construction Permit#: FROM TO DIAMETER , ITI IICKNESS MATERIAL
List all applicable hell consnircvion permits(i.e.UIG County,State,Pariance,etc.) ft. R. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM '1.0 DIAJIFTFIt SLOTsV',E I,IIICKNESS MATERIAL
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) I'JResidenlial Water Supply(single)
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lrri gatioll ❑Wells> 100,000 GPD FROJI TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 rt. 20 f'• GROUT POURED
❑Monitoring ❑Recovery ft. ft.
Injection Well:
rt. rt.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK 1'a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METIIOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑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•soiltrock type.grain size,etc.)
0 f`• 38 r`• DIRT
4.Date Well(s)Completed: 08-12-2022 Well ID# 38 f' 265 f' ROCK
5a.Well Location:
HENRY&CYNTHIS SWARTHOUT
Facility/Owner Name Facility IDS(inapplicable) ft. ft. 2023
1661 YODER FARM RD,.HICKORY, N.C. 28602 rt• rt. —
Physical Address,City,and Zip ft. ft.
CATAWBA 360901252902 1 11.REMARKS
Coady Parcel Identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one[at/long is sufficient) AcJe-0
catio35° 38.367 N 81° 20.935 ��, --- .t,;
8/12/2022
6.Is(are)the we,l(s): C1Permanent or ❑Temporary Signature or Certified Well Contractor Date
By signing this form,l hereby certffv that the well(s)was(mere)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or InNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Nell Construction Standards and that a copy
if this is a repair.,ill out known well construction information and explain the nature of the q/this record has hecn provider/to the well ownei%
repair under#21 remarks section or on the back of this farm.
23.Site diagram or additional well details:
8.For Geoprobe/DPT at-Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'Sce Ovcr'in Remarks Box).You may also attach additional pages if necessary.
drilled: �
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 265 ft.)For multiple wells list all depths ifdierctrt(e-samplae-3 200'and 2@100') ( Submit this G W-I 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 to Division of Water Resources (DWR),
ifwaler 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
12.Well construction method: 24c.For Water Supply and Open-Loop 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
Permit Program, 1611 MSC,Raleigh,NIC 1
13a.Yield(gpm) 0 � Method of lest:A I R ,27699-161
13b.Disinfection type: HTH Amount:
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Form OW-1 North Carolina Deportment of Environmental Quality-Division of Water Resources Revised 6-6-2015