GW1-2022-01481_Well Construction - GW1_20220120

WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only: k
I.Well Contractor Information:
CHAD HARTNESS ,�I,`�,a'
14.WATER ZONES
Well Contractor Name FROM I TO DESCRIPTION
2901 r 589 fL 590 ft. {�
JAM 2 Q L��� B
NC Well Contractor Certification Number ft. ft.,i't11�
;� ^�� +ct°C 15.OUTER CASING for multi-cased;wells OR LINER if a licable .
AIR DRILLING INC FROM TO I DIAMETER THICKNESS MATERIAL
Company Name �c;.: 0 ft 75 ft' 6 in. PVC
247224 16.iNNER CASINGOR TUBING eothermal closed-loo
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): ft. in.
Water Supply Well: 17.SCREEN -
FROMgr
TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public ft. in.
❑Geothermai(Heating/Cooling Supply) C1Residential Water Supply(single) ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GR❑Irrl atlon ❑WeIIS>100,000 GPD FROMTO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 20 ft• GROUT POURED
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge OGroundwater Remediation
❑Aquifer Storage and Recovery ❑Salim Barrier 19.SAND/GRAVEL PACK(if applicable)
tY FROM TO MATERIAL EMP1. CEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage ft. TO
❑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,soi0rock type,gmin size,eta
0 ft- 50 ft. DIRT
4.Date Well(s)Completed: 1 1-3-2021 Well ID# 50 ft• 605 ft, ROCK
Sa.Well Location: ft. ft.
BARRY KNOTT ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft ft.
2199 SANDY SPRING RD, HARMONY,N.C. 28634 ft ft.
Physical Address,City,and Zip ft ft.
IREDELL 4892435672 21.REMARKS
County Parcel Identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/iong is sufficient)
7J2.�q( fiCe n:
360 00.045 N 800 42.310 W I'
11/3/2021
6.Is(are)the well(s): ClPermanent or ❑Temporary Signature of Certified Well Contractor Date
i
By signing this form,i hereby certify that the we11(s)was(mere)constricted in accordance with
7.is this a repair to an existing well: ❑Yes or InNo 15A NCAC 02C.'.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
/ftbis is a repair,fill out known+vel/construction information and explain the nature of the of this record has been provided to the well owner.
repair under 1121 remarks section or on the hack 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: 605
({t)Fur multiple wells list all depths ijdifferent(example-3@200'and 2@I00') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 60 (ft.) 24a. For All Wells: Original form 4o Division of Water Resources (DWR),
1f rvaier level is above casing,use"+•. Information 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 t.e 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
i
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100.000 GPD:Copy to DWR,CCPCUA
13a.Yield(gam) 3 Method of test:
AIR Permit Program, 1611 MSC,Raleigh,NC 27699-1611
C13b.Disinfection type: HTH Amount:
Fonn GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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