GW1--00539_Well Construction - GW1_20240118

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WELL CONSTRUCTION RECORD (GW-1) For internal Use Only:
I.Well Contractor Information:
CHAD HARTNESS as WATER ZONES
Well Contractor Name • FROM to` •• DESCRIPTION
2901A 189 It. 190 ft. . . . i .
ft. ft. I I
NC Well Contractor Certification Number •
TI5.OUTER.CASiNG1for muttl-cased•ivells)OR LINER(rf ap licable)
AIR DRILLING INC FROM To DIAMETER' ' THICKNESS •MATERIAL
•Company Name 0 ft. 92 ft. 0 I In, PVC
36.INNER CASING OR TUBING(geothermal closed-loop) •
2,Well Construction Permit#: FROM 'CO DIAMETER' THICKNESS MATERIAI.
List all applicable well construction permits(i.e.I11C,County,State,Variance,etc.) ft. ft. In.
3.Well Usc(check well use): . ft. ft. fn.
Water Supply Well: , 17.SCREEN , , . - • , .
FROM TO DIAMETER ' SLOT SIZE •I'UICICNESS MATERLV,
Agricultural DMunicipal/Public ft. ft. In.
Geothermal(Healing/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
IndustriaVCommercial OResidential Water Supply(shared) 18,GROUT
irrigation FROM ' TO MATERIAL EMPLACEMENT SIETIIOD A AMOUNT
Non-Water Supply Well: 0 ft. Y0 ft. GROUT POURED
Monitoring ' DRecovery rt. ft.
Injection Well:
ft. ft.
Aquifer Recharge DGroundwater Remediation
Aquifer Storage and Recovery Salinit •Barrier •'19.SAND/GRAVEL_PACK(if applicable)
Y FROM TO MATERIAL . EMPLACEMENT METHOD
Aquifer Test 'DStormwater Drainage ft. ft.
Experimental Technology [,Subsidence Control ft. rt. ,
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets If necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM ro DESCRIPTION(color,hardness,soil/rock type,grain sic,etc.)
0 ft. 8E ft. DIRT
4.Date Well(s)Completed: 08-16-2023 Well ID# 82 ft, 205
ft. ROCK (; Tr^' /a Imo.
5a.Well Location: ft. ft. I s , 'i,,,,�^L.,t V P.—a"r`
DEW DROP FARMS I ft. ft. JAN 1 S 2024
Facility/Owner Name Facility ID//(if applicable) ft. ft.
338 FOSTER RD,MOCKSVILLE,N.C. 27028 ft. rt. Ifl T': •'cn 1--:7.-:,..,,N)..,,.;-.-3 i�r,.
Physical Address,City,and Zip ft. ft.
DAVIE ,21.REMARKS ,!(•'
County Parcel identification No.(PIN) `�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:' —
(if well field,one lat/long is sufficient) » !" —
22:‘Ct tific'�fiot:
35° 50.926 N 80° 39.963 i ri i
w `` '08-16-2023
6.Is(are)the wells)JPermanent or QITempornry Signature of Certified Well Contractor I Date 'if
a :b 1.•
By.signing this foram,I hereby certify that the tveil(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or ONo with ISA NCAC 02C.0100 or iSA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,Jill out known well construction it Jbramtion and explain the nature oldie copy of this record has been provided to the well owner.
repair under 1121 remarks section or on the back of this form.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 205 'VW
24a. For All Wells: Submit this,form within 30 days of completion of well
For multiple wells list all depths iifdiJJerent(example-3@200'l00'and 2Q100') construction to the following:
10.Static-water level below top of casing: 50 ft,
( ) Division of Water Resources,Information Processing Unit,
If-water fetal i.e above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6
(in.) 24b.For Infection Wells: 1n addition to sending the form to the address in 24a
12.Well construction method: above, also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.)
construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
I3a.Yield m 20 AIR
(gP ) Method of test: 24c.Fo•Water Supply cC Injection Wells: In addition to sending the form to
HTH the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed. I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources' ' Revised 2-22-2016