GW1-2022-01440_Well Construction - GW1_20220120

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: ^'
CHAD HARTNESS
14.WATER'ZONES'
Well Contractor Name e n FROM TO DESCRIPTION
2901 A ,P�� 2 2�?t �,k 489 ft. 490 ft. P
NC Well Contractor Certification Number r,r x c>`r,(�
.� 't�t•'�h;}Q�l 15:OUTER CASING for multi-cased wdl3ORLINER ifa licablc
AIR DRILLING INC �'''3' �'n' FROM TO DIAMETER THICKNESS MATERIAL
Company Name
0 ft- 97 fa 6in. PVC
W474 16.INNER CASING OR TUBING tothermal'dosed-loop)
2.Well Construction Permit#: FROM TO 1 DIAMETER THICKNESS I MATERIAL
Lilt all applicable well construction permits(i.e.UIC,County,Slate,Variance,ere.) ft• ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSI7.E THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) CJResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 78.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft- GROUT POURED
❑Monitoring ❑Recovery R. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
iR$AND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drain age
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothernal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling,Retum) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,ell.
0 rt. 87 ft. DIRT
4.Date Well(s)Completed: 9-8-2021 Well ID# 87 ft- 505 ft- ROCK
5a.Well Location:
DARYL ROBINSON ft. ft.
FacilityiOwner Name Facility 1D#(if applicable) ft. ft.
858 HUNTER BRIDGE RD,STONY POINT,N.C. 28678. rt. ft.
Physical Address,City,and Zip
ft. ft.
ALEXANDER 10963 2L REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient)
rtific n:
350 51.278 810 03.326 V
���
, '��T'9/8/2021
6.Is(are)the well(s): MPermanent or ❑Temporary Signature ofCerified Well Contractor Date
ey signing this form,I hereby certify that the we//(s)was(were)constructed in accordance with
7:Is this a.repair to an existing well:. ❑Yes or 4nNo 15A NCAC 02C.0100 or 15A NC•AC•02C.0200 Well Construction Standards and that a copy
jihisls a repair,fill out known iilell construction information and explain the nature of the of this record has been provided to the we/fowner.
repair under#21 rentarks section or of the back of this form.
• 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 construction info
construction,'only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in'Remarks Box).You may also attach additional pages if necessary.
drilled: .24.SUBMITTAL INSTRUCTIONS
•
9.Total well depth below land'sur 505'face: (170 Submit this GW-1 within 30 days of well completion per the following:
'!or nndtiple nvells.lisi all depths ff doerent jexample-3@200'and 2@100')
60 24a:'For All Wells:'Original form to Division of Water Resources (DWR),
10.Static water level below top of,casing: (ft.) Information'Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lfwater level is above casitig,use
11.Borehole diameter: 6 (in.) 24b.For.11dection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:
� 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e:auger,rotat�,cable,direct push,etc.) county environmental:health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
2 AIR Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: HTH Amount:
Form GW=l Noah Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018