GW1-2021-00479_Well Construction - GW1_20211222

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Informations
Chad Har the s s 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 0 ft, 119 ft. _0_ 1
2901 A 119 ft, 325 ft, 10 GPM
NC Well Contractor Certification Number 15.OUTER CASING for multl-eased wells OR LINER if ap Ilcable
Hickory Well Drilling Co. , Inc. FROM To DIAMETER THICKNESS MATERIAL
Company Name 0 ft, 119 ft 6 1 4iin !SR211 PVC
16,INNER CASING OR TUBING QaGtharmal closed-loop)
2.Well Construction Permit#: Irrigation / Farm FROM I TO I DIAMETER THICKNESS I MATERIAL
List all appl/eab/e well construction permits(i.e.U/C,Cuuniy,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. fG 1n.
Water Supply Well: 17.SCREEN
pp Y FROM TO DIAMETER I SLUT SIZE THICKNESS I MATERIAL
Agricultural Municipal/Public o ft. ft. in.
tGeothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in,
Industrial/Commercial OResidential Water Supply(shared) 187GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 20 ft• Bentonite Poured from To
Monitoring ORccovery
Injection Well:
Aquifer Recharge IO'Groundwater Remediatiorh
19.SAND/GRAVEL PACK if avallcabio
Aquifer Storage and Recovery E3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessar
FROM TO DESCRIPTION color,hardness soil/rock a rain stxe etc,
Geothermal Heatin Coolin Return) Other(explain under#21 Remarks)
0 ft, 110 ft• Dirt, Loose Rock
4.Date Well(s)Completed:l2/03/2021 WellID# 110 ft- 325 ft, Granite Bed Rock
5a.Well Location: ft. fr.
Todd Shuping ft.
a
Facility/Owner Name Facility iD#(if applicable) f
4593 Burkemont Rd. , Morganton, NC 28655 ft. rt' EC 2
Physical Address.City,and'Lip ft. ft.
21.REMARKS
Burke Unk.
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. rtf eatlon:
35.682574 N 81.697945 w /16/2021
6.Is(are)the well(s)OPermanent or OTemporary Signature of Certified Well Contractor Date
By signing,this form,1 hereby certih•that the ue/!(.r)was(were)constructed in accordance
7.1s this a repair to an existing well: [3Yes or J2No with 15A NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards•and that a
If this 1s a repair,f ll out known well construction Iglbrmatlon and explain the nature of the copy of thls record has been provided to ilia wall owner.
repair under#21 remarks section or on the back of this fort. 23.Site diagram or additional well details:
8.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
construction,only 1 GW-I i�needed. Indicate TOTAL NUMBER of wells construction details, You may also attach additional pages if necessary.
drilled; SUBMI7'7`AL INSTRUCTIONS
9.Total well depth below land surface: 325 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example.3@200'and 2r,100') construction to the following:
10.Static water level below top of casing: 47 (ft.) Division of Water Resources,Information Processing Unit,
1f water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
f
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Rotas Air Drilled above, also subunit one copy of this form within 30 days of completion of well
12.Well construction method: Sr construction to the following:
(i.e,auger,rotary,cable,direct posit,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) 10 Method of test:By Air Te s t 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Chl. Grans. Amount: 12 Ozs. (75%) completion of well construction toythe county health department of the county
where constructed.
Fortin GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016