GW1-2022-01455_Well Construction - GW1_20220120

WELL CONSTRUCTION RECORD(GW-1)- For Internal Use Only:
1.Well Contractor Information: 4�
CHAD HARTNESS 4, ^� 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
(,
O c�'`^ 269 ft 270 ft.
2901A �� '� ,N
NC Well Contractor Certification Number P
G pi
j 15.OUTER CASING for multi as wells OR LINER if a licable
AIR DRILLING INC ^^;`� FROM TO DIAMETER I THICKNESS MATERIAL
^, � 0 ft. 43 ft. 6 in. GALV
Company Name c ry
2020000065 L' 16.INNER CASING OR TUBING eothcrmat closed-loop)
2.Well Construction Permit#' FROM TO DIAMETER , THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Canty,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft ft. in.
Water Supply Well: 1FRD SCREEN
O DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft• f. in.
❑Geothermal(Heating/Cooling Supply) In Residential Water Supply(single) ft. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL 1 EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 ft• 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 ❑StormwaterDrainage 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) FROM TO DESCRIPTION color,hardness,soiurock type,grain size,etc.
0 ft 33 ft• DIRT
4.Date Well(s)Completed: 4-08-2021 Well ID# 33 ft• 285 ft• ROCK
5a.Well Location: ft. ft.
KENNETH BRANDON ft ft.
Facility/Owner Name Facility IDk(if applicable) ft. ft.
6696 N CAROLINA HWY49,DENTON,N.0 27239 ft ft.
Physical:address,City,and Zip
ft ft.
DAVIDSON 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) tifin:zz:
'"-u
350 33.769 N 800 41.308 W ---•4/8/2021
6.Is(are)the well(s): (lPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,/hereby certify that the rrell(s)was(were)constructed in accordance Nith
7.Is this a repair to an existing well: ❑Yes or MNo lSA NC'AC 02C.0100 or ISA NCAC 02C.0200 Well C'on.vruction.Standards and that a copy
If this is a repair,fi//out known Hell construction information and explain the nature of the 4f this record has been provided to the Nell 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 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: 285 (ft.) Submit this GW-I within 30 days of well completion per the following:
Far multiple Ne/Is list all depths ifd ffereni(etatnple-3@200'and 2 rd100')
10.Static water level below top of casing: 50 (fL) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is abase casing,use
Information
foration Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
"-"
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 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gP m) 30 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