GW1-2023-00552_Well Construction - GW1_20230104

l WELL CONSTRUCTION RECORD (GW 1) For Internal Use Only: i
1'Well Contractor Information:
CHAD HARTNESS
WERONEES"WCIIContractorNamC DESCRIPTION
2901A0 n.rt.NC Well Contractor Ccrlification Number
AIR DRILLING INC ING for multi-eased,ells OR LINER if a licable DIAMETER' THICKNESSMATERIAL
Company Name ft. 6 1 ,i"• PVC
174396 16.INNER CASING OR TUBING eotliernial closed-loo
2,Well Construction Permit#, FRO31 TO DIAMETER; THICKNESS I1fATERiAL
List all applicable xrll caustnrction permits(i.e.UIC,County,State, Varies ce,etc.)
3.Well Use(check.well use): ft. R. in.
17 SCREEN
Water Supply Well: .
❑Agricultuml FROM TO DIAMETF,RI St. TSIXF THICKNESS MATERIAL
b ❑MunicipaUPublic ft. rt. in.
❑Geothenal(i-leating/Cooling Supply) [!]Residential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) ft.
IN.GROUT
❑Irri ation ❑Wells> 100,000 GPD FROM TO hIATERIAL EMPLACEMENT METlfOD&AMOUNT
Non-Water Supply Well:❑Monitoring ❑Recovery 0 1t. 20 ft• GROUT POURED
ft. ft.
Injection Well:
❑A uiferRechar a f. f.❑GroudaterRemeaton❑Aquifer Storage and Recovery ❑Salinily Barrier •19.SAND/GRAVEL PACK if a licable
FROM TO MATERL\L EMI'LACEMENTMETHOD
❑Aquifer Test ❑Storinwaler Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets'if necessar
❑Geothermal(I-Icating/Cooling Return) ❑Other(explain under#21 Remarks) I
FROM TO DESCRIPTION(color,hardness,soiltrocktype.grain size,etc.
0 rt. 71 rt• DIRT
4.Date WeII(s)Completed: OS-05-2022 Well ID# 71 rt• 365 ft ROCK
Sa:Well Location: ft. ft.
DAVE WIGFIELD 1t. ft. �������;''�� u�,'t.�•
Faeility/Owner Name Facility IDN(ifapplicable)
2093
1311 LIVE OAK RD, CATAWBA,N.C. 28609 rt; rt. -
Physical Address,City,and Zip ft. ft. c .mni• ?f ti_' �:fl J
CATAWBA 470002952449
21.REMARKS —
County Parcel identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Iat/long is sufficient) 2 rtifi on:
350 40.408 N 80- 59.431 W
' -8/5/2022
6.Is(arc)the well(s): ClPermanent or ❑Temporary Signature of Certified Well Contractor c Date
By signing this form,I hereby cer1gj,that the ivell(r)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or InNo 15A NCAC 02C.0/00 or 15A NCAC 02C.0200 IVe11 Construction Standards and that a copy
Ifthis is a repair,fill out known ivell construction in formation and explain die nature ofthe ofthis record has been provided to the well onaner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the saine 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'Sec Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 365
For multiple wells list all depths ifdi�ereru(esanhple-3 rr 200'and 2 a 100q (f t•) 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 'to Division of Water Resources (DWIt),
If water level is above casing,use"+' Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
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11.Borehole diameter: 6 24b.For Injection Wells: Copy to DWR, Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-11636
12,Well construction method:(i.e.auger,rotary,cable,direct push,etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells•Copy to the
county environmental health department of the county where installed
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FOR WATER SUPPLY WELLS ONLY: f ,
24d.For Water Wells producing over 100,000 GPD• Copy to DWR,CCPCUA
13a.Yield(gpm) 25 Method of test AIR perm Program,1611 MSC,Raleigh,NC 27699-1611
I3b.Disinfection type: HTH Amount
Form OW-1
North Carolina Department of Environmental Quality-Division of Water Resources I Revised 6-6-201 S
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