GW1--00583_Well Construction - GW1_20240118

WELL CONSTRUCTION RECORDGW-1 I Print Form
) For Internal Use Only: I
1.Well Conlraclnr Info motion: I
CHAD HARTNESS
--� —' 14.WATER ZONES ' '
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Well I. erector Name FROM TO .' DESCRIPTION
2901A 209 ft• 300 ft.
1 '
ft. ft.
NC Well Contractor Certification Number
AIR DRILLING INC I5.OUTER CASING(for multi-cased wells)OR LINER((f ap limbic)
FROM 'f0 f DIAMETER THICKNESS MAMMAL
Company Name 0 IL1U7 fl• 6 in• PVC
12683 16.INNER CASING OR TURING(geothermal closed-loop)
2.Well Construction Permit i1: FROM To DIAMETER THICKNESS MATERIAL.
List all applicable well runstria'Iion permits(Le.U/C.',Coonty,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. I, in.
[Water Supply Well: I7.SCREEN •
(-1 \!11•icllll(Ir:ll FROM '1.0 DIAMETER r SLOT'SIZE 'I'111CKNE.SS MATERIAL
4-', • Municipal/I ublic 1't. ft. in.
Geothermal tl IeatingiCooling Supply) DResidc11lial Water Supply(single)
luelustrial/Commcrciul DResillential WaterSupply(shared) ft.18.GROUT ' ft. in,
'Irl•i;iUtion FROMTOMATERIAL EMPLACEMENT Ammon Nun-Water Supply Well:
Monitoring
Injection\Vela:
0 fl• 20 ft. GROUT POURED
DRecovery rt.
':\c)uiler Recharge CI. ft.
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DGroundwatcr Remcdiation
\qui lie Storage and Recovery SalinitI9.SAND/GRAVEL PACK(If applicable)
� y Barrier FROM TO MATERIAL EMPLACEMENT METIIOD
Aquifer Test Ostormwatcr Drainage . ft. ft. •
li.\perimetutl Technology QiSubsidence Control ft. I't. '
Geothermal(Closed Loop) ❑(')'racer 20.DRILLING LOG(attach additional sheets if necessary)
:Geothermal(Pleating/Cooling Return) n!Olite•(explain under 1121 Remarks) Mom 'I'O DESCRIPTION(c°I°r,hardness,s°IUroet<lypc,grate size,etc.)
0 ft. 97- it. DIRT i .
.1.Date Wells)Completed: 08-08-2023 Well ID!! 97 ft' 305 ft. ,
ROCK
ft. rt. �-- +�" ,a rs�Sa. Nell Location: ' 6 ' . I✓r "'-.
'VIDAL ACEVEDO ft. rl.
i �/
Facilily' ,.ucrName Facility ID//(ifapplicahle) ft. ft. J�i�l 1 LUL4
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3958 HOLLYWOOD RIDGE RD,LENOIR,N.C. 28645 ft. rt. iy
Gt'I.-.,,, (^:, Par,.7.,: ri 1 to
Physical,\ddres,..City.and Zip ft. ft. .�. Oa.
cALDweLLI DWC:u�G
2852059871 • 21.REMARKS
County Parcel Identification No.(PIN)-`
Sb.Latitude anti longitude in degrees/minutes/seconds or decimal degrees: '
(if well field.one IaClong is sn1'Iicient)
35° 59.553 81° 31.934 �
N `\,�t,-.6� - w'e
.. 08-08-2023
G.Is(are)the well(a)EX(Permanent or D l'enlporary Signature ofCdrtifed Well Conlraclor Date
/11'signing this final,1 hereby certify that iihe tmll(4 was(were)constructed in accordance
7. Is this a repair to an existing well: DYes or DNo with 15:1 NC1C 02C.0/00 or 1SANCAC 02C.0200 Well Construction Standards and that a
Ilan-,is a repair.1i/I out known well cansi,,,•tion inlinvoliun and expla/n the moan o/7hc, copy of this record has been provided to the,well muter.
report under n2/rc•raarks.section or on the bock gl'this jinni.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.For Ceoprobe/DP'1'or Closed-Loop Geothermal Wells having the same
construction details. You may also attach additional pages if necessary.
construction,only l GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
SUBMITTAL INSTRUCTIONS
9.'Intel well depth below hand surface: 305 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Far nm/a/t/e ur//s/ia ail deaths ifc(if)c•rrnl texanplr-4:r 200'and 2©100')
construction to the following:
111.Sl:tlie,voter level belowlop of casing: 50 (ft.) r r
Division of V1 tie Resuurces,•htfarmation Processing Unit,
1/':ro ar let,1 isor uhr Pas/nt„use'•I" •
1617 Mail Service Center,Raleigh,NC 27699-I617
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11.Borehole diameter: 6 (in.) 241). For Injection Wells: In additioin to sending the form to the address in 24a
12.Well construction ntelhod: above, also submit one copy of this foin within 30 days of completion of well
(i.c.auger.rosary.cable,dirwl push.etc.) construction to the following:
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Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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I3a.Yield Igpm) 20 Method of test: AIR 24e. For Water Supply S Injection Wells: In addition to sending the form to
H fl-1 the address(es) above, also subliiit due copy of this form within 30 days of
131).Disinfection type: A mount: completion of well construction to the county health department of the county
where constructed.
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Form i i\\'-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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