GW1-2022-01448_Well Construction - GW1_20220120

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: ��y3
NEILL PARDUE
Jf.. ft) M,,WATER ZONES
'`FROM TO DESCRIPTION
Well Contractor Name k`� r•C 429 ft 430 ft.
2609A O
NC Well Contractor Certification Number �QC' ^,'�'r 15.OUTER CASING for multi cased wells OR LINER if a livable
INCr,7
AIR DRILLING, C .,�'�(�J FROM TO DIAMETERi THICKNESS MATERIAL
0 ft- 70 ft. 6 iin. PVC
Company Name �' 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 06-201 9-1 1 71 93 !y'' FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) ft ft in•
3.Well Use(check well use): ft ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER !SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft. in-
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑trrl ation ❑Wel Is>100,000 GPD FROM TO MATERIAL' EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 It- 20 It- 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 I EMPLACEMENT METHOD
❑Aquifer Test ❑Stonnwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control rL ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 921 Remarks) FROM TO DESCRIPTION color,hardness,soiltrock type,grain sae,etc.
0 ft 60 ft• DIRT
4.Date Well(s)Completed: 3-9-2021 Well ID# 60 It 445 rt- ROCK
Sa.Well Location: ft ft.
KALEB COVINGTON ft ft
Facility/Owner Name Facility ID#(if applicable) ft ft.
1376 ROUNDSTONE RD,SHERRILLS FORD, N.C. 28673 ft ft
Physical Address,City,and Zip ft ft.
CATAWBA 461902694016 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(.if well field,one Iat/long is sufficient) 22.Ce
350 39.185 N 800 57.531 W P9& 3/9/2021
6.Is(are)the well(s): MPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing thisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or QNo 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a copy
!f 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 dt21 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: 445 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3 a 200'and 2 cr 100')
70 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
!f 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
i
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 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) 20 Method of test: AIR
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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