GW1-2022-01447_Well Construction - GW1_20220120

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: ,,P
CHAD HARTNESS �4a.WATER ZONES
'FROM TO DESCRIPTIONS
Well Contractor Name O e n 389 It 390 fL j
2901A
NC Well Contractor Certification Number
,P � •✓f3'� 15.OUTER CASING for multi-cased wells OR LINER if a licabte
AIR DRILLING INC ' FROM TO DIAMETER THICKNESS MATERIAI.
G ft 40 ft. 6 in. GALV
Company Name j'
O5-ZO19-1166�'� 16.INNER CASING OR TUBING(geothermal closed-loop
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UiC.County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): M ft. in.
Water Supply Well: ' SCREE
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) It Residential Water Supply(single) ft. fr. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wel Is>100,000 GPD FROM I TO MATERIAL' EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 10 fL 20 ft- GROUT POURED
❑Monitoring ❑Recovery ft. ft.
injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK ifs livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL - EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 1
FROM TO DESCRIPTfON color,hardness,soiVrock type,grain size,etc.
0 ft- 30 ft. DIRT
4.Date Well(s)Completed: 4-22-2021 Well ID# 30 ft. 405 ft- ROCK
5a.Well Location: ft. ft.
JOHN CARPENTER ft ft.
Facility/Owner Name Facility[D#(ifapplicable)
ft. ft.
4792 NORTHCREST ST,CLAREMONT,N.C. 28610 ft ft.
Physical Address,City,and Zip
ft. ft.
CATAWBA 377403305710 21.REMARKS
County Parcel Identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ---
(ifwell field,one Iat/long is sufficient) 1z'
c on:
35° 45.591 N 81006.450 W �"- -�4/22/2021
2►� -_..._ ._
6.Is(are)the well(s): 19Permanent 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 19No I5A NCAC 02C.0100 or 15.4 NCAC 02C.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 121 remarks-section or on the back of this form.
23.Site diagram or additional well details:
S.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-i 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: 405 (ft) Submit this CW-1 within 30 days of well completion per the following:
F'or multiple wells list all depths if dierent(example-3@200'and 2@100')
I
40 24a. For All Wells: Original form to'Division of Water Resources (DWR),
0' Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is shove casing,use
24b. For Injection Wells: Copy to DWR,Underground injection Control(lUC)
11.Borehole diameter: 6 (in,)
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 departmeht of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield m 20 Method of test: AIR Permit Program,1611 MSC,Raleigh,NC 27699-1611
(gP )
13b.Disinfection type: HTH Amount:
i
Form G W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018