GW1-2022-01446_Well Construction - GW1_20220120

WELL CONSTRUCTION RECORD(G% / For Internal Use Only:
4)`"t n �.
1.Well Contractor Information: '
CHAD HARTNESS 14.WATER.ZONES
Well Contractor Name FROM TO DESCRIPTION
2901 A �P " "'
� fr. ft.
NC Well Contractor Certification Number ;' 15.OUTER CASING for mu'ft—
ti cased welts OR LINER if a licable
AIR DRILLING INC FROM To DIAMETER THICKNESS MATERIAL
"' 0 ft 48 ft. 16 tin• PVC
Company Name
16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: 148898 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UiC,County,State, Variance,etc.) fL ft in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
pp y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) (nResidential Water Supply(single) fL fL in.
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 rL GROUT POURED
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft.
❑Experimental Technology ❑Subsidence Control fL ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soittrock type,grain size,etc.
0 It 38 ft- DIRT
4.Date Well(s)Completed: 6-1 1-2021 Well ID# 38 fL 205 ft- ROCK
5a.Well Location: fL ft.
MSL HOMES fL ft.
Facility/Owner Name Facility iD#(if applicable) ft, ft.
3980 KAISER ISLAND RD,TERRELL,N.C. 28682 fL ft.
Physical Address,City,and Zip fL ft.
CATAWBA 461704637073 21.REMARKS
County Parcel Identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) tifica n:
350 34.599 N 800 57.416 W � � ---
-fi/11/2021
6.Is(are)the well(s): CJPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONO i5A NC'AC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well,owner.
repair under�'21 remarks section or on 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 1 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 surface: 205 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3@200'and 1@100')
50 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
If water level is above casing,use"="
11.Borehole diameter: 6 (in.) 24b. For Injection 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,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 1100,000 GPD:Copy to DWR,CCPCUA
25 AIR Perm it Program, 1611 MSC,Raleigh,!NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: HTH Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018