GW1-2022-01479_Well Construction - GW1_20220120

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: c^c�-
CHADHARTNESS
34.-WATER ZONES
Well Contractor Name i/1 A 1 L . ROM TO DESCRIPTION
2901 A J H FV FE89 ft 390 ftft ft
NC Well Contractor Certification Number
15.OUTER CASING- for mutd-cased welts OR-LINER if a liaa"r -
AIR DRILLING INC FROM TO _ DIAMETER THICKNESS MATERIAL
Company Name
0 ft 37 ft. 6 in. PVC
320120 16.INNER CASING OR'TUBING m eotheral closed-loon)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i,e.UIC,County.Stale.Variance,etc.) tt ft in.
3.Well Use(check well use): ft It. in.
Water Supply Well: 17.SCREEN =
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) fr. tr. in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
18 GROUT: ,
❑1rri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft GROUT POURED
❑Monitoring ❑Recovery ft ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation ft ft.
❑Aquifer Storage and Recovery ❑Salmi Barrier .19.SAND/GRAVEL PACK if a liable
ty FROM TO I MATERIAL I EMPLACEMENTMETHOD
❑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) I
FROM TO DESCRIPTION color,hardness soil/rock type, •n sim etc
0 ft 27 ft DIRT
4.Date Well(s)Completed: 11-17-2021 Well ID# 27 ft 405 ft- ROCK
5a.Well Location: ft ft.
DEE FARRELL ft ft
Facility/Owner Name Facility ID#(if applicable) ft ft.
279 WOOD DUCK LOOP,MOORESVILLE,N.C. 28117 ft tit
Physical Address,City,and Zip ft It.
IREDELL 4646059774 21REMARKs
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) ej
ertif lion:
35° 33.536 N 80° 52.481 W
�' 11/17/2021
6.Is(ore)the well(s): CJPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby Geri fy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 19N0 15A NCAC 02C.0100 or 15A 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#2I 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-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
For multiple wells list all depths ifdierent(example-3(?a 200'and 2Q100') ( ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 20 (ft) 249. For All Wells: Original form;to Division of Water Resources (DWR),
If water level is above casing,use"+" Information Processing Unit,1617 MSC;Raleigh,NC 27699-I617
11.Borehole diameter: 6 (in,) 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
i..Well construction method: 24c.For Water Su 1 and O en-Loo Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct posit etc.) county environments health department of the county w ere msta 1
FOR WATER SUPPLY WELLS ONLY: 'I
24d.For Water Wells aroducing over 100.000 GPD: Copy to DWR,CCPCUA
5 AIR Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: i
13b.Disinfection type: HTH Amount:
i
r
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources } Revised 6-6-2018
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