GW1-2023-00558_Well Construction - GW1_20230104

I WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only:
1.Well Contractor Information:
CHAD HARTNESS
14:WATER'ZONES "
Well Contractor Name FROM TO DESCRIPTION
2901 A 788 fL 790 rt. ft.
NC Well Contractor Certification Number �
iA5..0UTER CASING for multi-cased wells oR LINER if.a'`)icable i
AIR DRILLING INC FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft- 107 ft. 6 ! in. GALV
21-276 16ANNER CASING"OR TUBING !eotiie rural closed-loo ' _
2.Well Construction Permit#: FROM TO CKNESS DIAMETER I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,eta) ft ft. TH
in.
3.Well Use(check well use): ft. ft. ! in.
Water Supply Well: '47.SCREEN,
❑A cultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Municipal/Public fL ft. in
❑Geothermal(Heating/Cooling Supply) nResidential Water Supply(single)
ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) -
18.GROUT-
❑Irri ation ❑Wells>100 000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft. GROUT POURED
❑Monitoring ❑Recovery to ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation ft ft.
❑Aquifer Storage and Recoveryi 19.SAND/GRAVEL PACK if a "lic6ble
❑Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control fL fr.
❑Geothermal(Closed Loop) ❑Tracer 20:DRILLING LOG adach additionafsheets if.necessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION color hardness solUroek a roia sae etc.
0 tt. 97 rr. DIRT
4.Date Well(s)Completed: 1-12-2022 well ID# 97 ft. 805 ft. ROCK ,
So.Well Location: ft. ft.
SOUTHERN COTTAGE ft ft.
. t
Facility/Owner Name Facility ID#(if applicable) ft• ft P-
8610 Arbor Oaks Ct . Concord , N. C 28027 ft. ft. n -"
Physical Address,City,and Zip ft ft. j 1
CABARRUS ,.zL-,nMARKs
County Parcel Identification No.(PIN) 1f1S0 J�gf�vOG
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(35if 1125.530
N ongisstifficient) 80 43.179 � anon:
W --'--- -F, 1/12/2022
6.Is(are)the well(s): InPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)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 Well Construction Standards and that a copy
Ifdds is a repair,fill out known'Pell construction information and explain the nature of the of flits record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
S.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 I is needed. Indicate TOTAL NUMBER of wells (add'See Ovee in Remarks Box).You may also attach additional pages if necessary.
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 805
(ft.) Submit this GW-1 within 30 days of well completion per the following:
For mrdtlple wells list all depths ljd�erent(erontpie-3@200'and 2@100')
I
10.Static water level below top of casing: 20 (fG) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use +" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection Wells:Copy to;DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
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 ofthe county where Iled
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells producing over 100 000 GPD• Copy to DWR,CCPCUA
139.Yield(gpm) 5 Method of test; AIR Permit Program,1611 MSC,Raleigh',NC 27699-161.1
13b.Disinfection type: HTH Amount:
I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6.6.2018