GW1-2021-00931_Well Construction - GW1_20210305

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only.
1.Well Contractor Information:
Chad Hartness M14.WATERZONESZONESTO Weil Contractor Name 5OO ft, 1 2 GPM
2901A 585 ft' 7 1 2 GPM
NC Well ContractorCertification Number ASING for multi-eased wells OR LINER ifa flcableHickory Well Drilling Co. , lnC. '1'0 ff DIAMI:1nR In 'IlIIAL
CK1ESa MAtruI37 6 1Company Name ASING OR TUBING eatMrmal elmed4002.Well Construction Permit#: WELL-09-2020-137961 TO Lrrr all applicable wvll con,nvrnon pernw,(Lc. L'IC.Cnnnp.Srote. Vmroneerr) ft.
fit n.
3.Well Use(check well use):
Water Supply 17.SCREEN Well: saoM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ❑Municipal/Public 0 «. «• In.
Geothermal(Heating/Cooling Supply)XfIResidential Water Supply(Single) ft. ry, in.
Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 f`• Bentonite Poured from To
Monitoring ❑Recovery ft' ft.
Injection Well: ff. fit.
Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ifa IlcaMe
Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ❑IStormwater Drainage ft. ft.
Experimental Technology ❑Subsidence Control ft. ft.
Geothemsal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets If necessa
aolVroca a atn,be ate,
Geothermal(Hearin Conlin Return)
DESCRIPTION color Irnr4neu
) Other(explain under 92l Remarks) 0 ft. 3TD0 ft- Dirt, Cla LOOS- V-1,
4.Date Well(s)Completed:01/29/2021well ID# 30 fL 585 ft Granite
ft. ft.
Set.Well Location: Name on permit
n. «.
Coast to Coast Properties (Belinda Hunt)
Facility/0wne,Name Facility lDq(ifapPlicable) fit, ft.
3714 Thompson St. , Newton, NC 28658 ft. ft.
n.
Physical Address,City,and Zip
Catawba 371118218470 21.REMARKS
County Parcel Identification No.(PIN)
5b,Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one taVlong is sufficient) 22.Certification:
N 35.682622 81.313990 W 1/ Q1 /ICJ n? 27/2021
6.Is(are)the well(e)f3Permanent or ❑'temporary
Stgt o en,¢d Wel Conimcmr Date
BI'.rigrring in.pa,l Aercb}'cerrrj,,'that the rell(r)wa.r (were)contfrucled in accordance
7.Is this a repair to an existing well: ❑Yes oKioNo a nl,15A NCAC 02C 0100 or 15A NCAC 02C 0200 Well Conaln cairn Standards and that a
/f/Nis Lv a repair,JI!]and knman well conrlruc0nn In#rrmatlnn cord a'plmn Ihr native o fMe copy u f rir8 record hur peen provided ro the well her
repad under#21 remaois section or on the back ofthls(arm. 23.Site diagram or additional well details:
R.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
ils. You may also attach additional pages if necessary.
construction,only 1 GW-- needed, Indicate TOTAL NUMBER of wells construction de
drilled:drilled: A SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 585 —(ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
Formalliplex'ell5lirla/(deY/hs if rliffn'en((exaniple-3�2llll'an02(a41(W} construction to the following:
10.Static water level below top of casing: 60 (ft.) Division of Water Resources,Information Processing Unit,
11 uvler level rs above earing.a,e 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b. For Injection Wells: In addition to sending the form to the address in 24a
Rotary Air Drilled above, also submit one copy a this form within 30 days of completion of well
12.Well construction method: Y construction to the following:
(i c.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 8 Method of test: By Air Test 24c. For Water Supply& Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this fora within 30 days of
13b.Disinfection type: Chl. Grans. Amount: 21 OZs. (75%) Completion of well construction to the county health department of the county
where constructed.
Form G W-I North Carolina Depannrent of Environmental Quality-Division of W ater Resources Revised 2-22-2016