GW1-2022-01502_Well Construction - GW1_20220120

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WELL CONSTRUCTION RECORD(GW-1) Por Internal Use Only:
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1.Well Contractor Information:
CHAD HARTNESS a.wATER ZONES,
Well Contractor Name a"'S; FROM TO I DESCRIPTION
2901 A 'D ` 889 ft- 890 ft-
ft. ft.
NC Well Contractor Certification Number n 1\k
JN rt�rce " 15.OUTER CASING for multi-cased wells IN OR LINER ifa Iicable
AIR DRILLING, INC ,j �CG n"Q� FROM TO DIAMETER THICKNESS MATERIAL
Company Name , .vs;"-�+�jVt`,—;,,, ,.
0 fr. 64 ft. 16 in, PVC
237908 16.INNER CASING OR TUBING eothermal closed-loon)
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) ft. ft.
3.Well Use(check well use): ft. fL in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAI-
❑Agricultural ❑Municipal/Public ft. fa in.
❑Geothermal(Heating/Cooling Supply) [!]Residential Water Supply(single) ft. ft. in.
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) IS,GROUT
❑Irrl ation ❑Wel Is>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ri- 20 ft- GROUT POURED
❑Monitoring ❑Recovery ft. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation ft. fr.
19.SAND/GRAVEL PACK ifa Iicable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO I MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
❑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,soil/mck I re,grain siu,etc.
0 e. 54 rt. DIRT
4.Date Well(s)Completed: 08-25-2021 Well ID# 54 rt• 905 rt• ROCK
5a.Well Location:
PEACHTREE RESIDENTIAL
Facility/Owner Name Facility 1D#(if applicable) ft. ft.
113 BROAD BIRCH DR, LOT#17, DAVIDSON,N.C. 28036
Physical Address,City,and Zip ft. ft.
IREDELL 4664875050 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one lattlong is sufficient) �2 Certi atio
35° 30.532 N 80° 47.104 /V
� .�
8/25/2021
6.Is(are)the well(s): InPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,/herchy certify that the we//(s)n•as(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or l!lNo /SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
/f this is a repair,fill our known well construction information and explain the nature of the of this 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'Sce Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 905 (ft.)
hormultiple wells list a//depths ifdiiferent(example-3 tt 100'and 2@100') Submit this GW-I within 30 days of well completion per the following:
10.Static water level below top of casing: 50 (rt) 24a. For All Wells: Original form to Division of Water Resources (DWR),
/f water level is above casing,use Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
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11.Borehole diameter; 6 (in) 24b. For Injection Wells: Copy to DWR, Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
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.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
6 AIR Permit Program,1611 MSC,RalcighJNC 27699-161 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: HTH Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-201 S
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