GW1--00650_Well Construction - GW1_20240119

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
I.Well Contractor Information:
CHAD HARTNESS I , I
14.WATER ZONES 1 1
Well Contractor Name
mom To DESCRIPTION
2901 A 249 ft• 250 ft. I I --
NC Well Contractor Certification Number fl' ft' I I
AIR DRILLING I N C IS.OUTER CASING(for multi-ensedlwdlls)OR LINER(If ap all icnble) AL
GR(7\I_ 'fo DIAa1i:1'6:R I 111CKNSS _1I,\'IY?1(1
Company Name 0 rt. 99 R. 6 I In. PVC
370246 16,INNER CASING OR TUBING(gebthernua closed-loop)
2.\Nell Construction Permit Il: `Rom- .-O D.aM?'IR ' 'incI:NESs - -'e a rri.,_.___ ._-
ltrt all applicable well construction permits(.e.(/lL,County,State,Variance,wed I , fl, ),,
3.Well Use(check well use): ft. ft. In. ------`
Water Supply Well: 17.SCREEN I
❑Agl'letlltlil.al ❑M , FROM ' TO DIAMETER I SLOT SIZE'. THICKNESS MATEEItiAL
unicipal/I ublic ft. ft. in,
❑Geothermal(Healing/Cooling Supply) l'JResidcntial Water Supply(single)
ft. ft. In.
❑Industrial/Commercial ❑Residential Water Supply(shared)
18.GROUT
❑Irrigation ❑Wells> 100,000 GPD FROM TO • MATERIAL EMPLACE.\IENTMETIIOD&AMOUNT
Non-Water Supply Well: Q ft. 20 ft• GROUT POURED
❑Monitoring ❑Recovery ft. ft• -
I n,jection Well:
•
I:IAquil'er Recharge I!Groundwater Rcmediation ft. 1'i.
ClAquilcrStorage and Recovery 19.SAND/GRAVEL PACK In placable)
Y ❑Saliliily Barrier FROM To - ' MATERIAL EMPLACEMENT METIIOtl
1JAquilbr'lest ❑StormwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control ftL ft. l;
C1Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
LiGeothermal(Heating/Cooling Return) IJother(explain under iP21 Remarks) moat ro nEsc(tir PION(color,hardness.soli/rock I r rn(n size,ir�_
0 ft. 89 II. DIRT i
4. Date Well(s)Completed: 01-1 0-23 Well wit_ 89 I•'• 265 ft• ROCK l - -. -
5a.Well Location; Il. I'L I
TREXLER CONSTRUCTION rL-- rl. ` �-
Facility/Owner Name Facility ITN/(if applicable) ft. I'l. 1''
1168 LILAC LANE,SALISBURY,N.C. 28147 ft. ft. 1' •�41�! - -L�j�4-
Physical Address,City,and Zip fL fh t11+vPr;:F i� ? ,C,
ROWAN I. . 4)!
458D008 2hREMARKS n-y r
County Parcel Identification No.(PIN) •
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Orwell field,one let/long is sufficient) f
35° 40.295 N 80° 32.895 N 22�( jlieatiol ,
(' rr
r�'::�4. /41. --1* .';'."-----,...' .:1,/'10/2023
6.Is(are)the well(s): ClPermanent or ❑Temporary Signature of Certified Well Contractor 1;
1,
By signing this farm,1 hereby cerli/j'that the well(.t)terns(were)constructed in accorrlrrnce with
7.Is this a repair to an existing well: ❑Yes or ItNo 1.5;1 NCAC 02C.0/00 or 15A iVL;•iC 02C;.0200 II'e//Construction Standard,.and that a eapr
If ihi a IV a repair.fill out known well constructionh(/brntatiat and explain the nature of the 4f this record has horn provided to the well tanner.
repair under 112/remarks suction or on the back of this firm. 1 .
23.Site diagram or additional well details:
You may use the back of this page to'provide additional well construction info
8.For Geoprobe/DPT or Closed-hoop Geothermal Wells having the same
construction,only I GW-I is needed. Indicate TOTAL.NUMBER of was (add'See Over'in Remarks Box).YouMay also attach additional pages if necessary.
drilled:..--------__T I.
24.SUIIMI'I'TAL,INSTRUCTIONS'
9.'I'otal well depth below land surface: 265 ft.
For multiple wells list all depths i/'dil)erent(example-3@)200'and 2��)100') ( ) Submit this GW-1 within 30 clays of well completion per the following:
(it• 24a. hm All Wells: Original form Ito Division of Water Resources (l)WR).
10.Static water level below top of casing; 30
I/'water•level is above easing,use"+^ ) Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
24b.For Injection Wells: Copy to DWR, Underground Injection Control(IUC)
11.Borehole diameter: 6 (in.)
Program, 1636 MSC,Raleigh,NC 27699-:9636
12. fell construction method: 24c.For Water Supply and Open-Latin Geothermal Return Wells:Copy to die
auger,(i.e. rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 11 24d,For Water Wells producing over 1)00,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) 5 Method of test: AIR Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: H Amount:
Form C1W-I North Carolina Department of Environmental Quality-Division of Water Resources
Revised 0-6-:.01
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