GW1-2022-01497_Well Construction - GW1_20220120

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
CHAD HARTNESS
t1 *v 14.WATER ZONES
Well Contractor Name � t,6' 1'j•' FROM TO DESCRIPTION
el?_01 01' r ' 709 It- 710 ft.
2901 A ,�: cy �,.
rr'(..C� ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING for multi cased wells OR LINR if a licable
AIR DRILLING INC � �� FROM TO DIAMETER TH. .NECSS MATERIAL
0 fL 82 ft. 6 in. PVC
Company Name '�'' V 16.INNER CASING OR TUBING eother al closed-too
2.Well Construction Permit#: 242748 1�''. FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,Coumry,State, Variance,etc) ft ft. in.
3.Well Use(check well use): fL ft. in.
Water Supply Well: M SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ClResidential Water Supply(single) ft. ft. in.
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
❑Irri ation ❑Wel Is>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: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑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,soillreck type,grRin size,etc.
0 ft• 72 ft- DIRT
4.Date Well(s)Completed: 4-30-2021 Well ID# 72 1- 725 ft- ROCK
5a.Well Location:
fL ft.
LAKEMIST HOMES fL ft.
Facility/Owner Name Facility ID#(ifapplicable) fL ft.
141 HIDDEN MEADOWS DR,MOORESVILLE,N.C. 28117 fL ft.
Physical Address,City,and Zip
ft f,
IREDELL 4649028098 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: _
(ifwell field,one lat/long is sufficient) 2. vtir. o
n
350 38.139 N 800 52.479 W ---- -R-,
4/30/2021
6.Is(are)the well(s): IlPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing thisform,l hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or InNo 15.4 NCAC 02C.0/00 or ISA NCAC 02C.0200 Well Construction Standards am(that a copy
If this is a repair,fill out known well construction information and explain the nature of the gfthis record has been provided to the well 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: 725 (ft)
For multiple wells list all depths ifdifferent(example-3@200'and 20100) Submit this GW-1 within 30 days of welt completion per the following:
rj0 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
Ifwater 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
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) 25 Method of test: AIR Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: j
t
I
Fonn GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018