GW1-2022-01504_Well Construction - GW1_20220120

WELL CONSTRUCTION RECORD(GW-1) _ For Internal Use Only:
1.Well Contractor Information:
CHAD HARTNESS r4wATER ZONES
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Well Contractor Name O L FROM TO DESCRIPTION
2901A ,P�� 1 .j 789 ft- 790 fL
e. fL
NC Well Contractor Certification Number ,�
E '"'t �`��'O� 15.OUTER CASING for multi-cased wells OR LINER if a licable
AIR DRILLING INC � ; FROM TO DIAMETER' TIIICKNESS MATERL�L
Company Name 0 ft' 85 ft. 6 in, PVC
.�13847 16.INNER CASING OR TUBING cothermal closed-loo
2.Well Construction Permit#: FROM TO I DIAMETER I TIIICKNESS I MATERIAL
list all applicable well construction permits(i.e.111C,CotugK State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public IL ft. in.
❑Geothermal(Heating/Cooling Supply) InResidential Water Supply(single) f. ft. in.
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18•GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 It- 20 ft- GROUT'. POURED
❑Monitoring ❑Recovery R. rL
Injection Well:
ft. fL
❑Aquifer Recharge ❑Groundwater Remcdiation
❑Aquifer Storage and Recovery ❑Salinit Bier 19.SAND/GRAVEL PACK if a licable
yarr FROM TO MATERIAL EMPLACEMENTMETIIOD
❑Aquifer Test ❑Stormwater Drainage ft. fr.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20 DRILLING LOG attach additional sheets if necessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,gmin Sim,etc.
0 rt. 75 rr. DIRT
4.Date Well(s)Completed: 9'7-2021 Well ID# 75 ft• 805 ft• ROCK
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5a.Well Location:
RYAN PIERCE
Facility/Owner Name Facility ID#(if applicable)
279 ABNER RD,STONY POINT,N.C. 28678 a. rt.
Physical Address,City,and Zip ft. ft.
IREDELL 4707598136 2l.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Iattlong is sufficient) &ei '
35° 52.221 N 81001.818 W 9%7/2021
6.Blare)the well(s): MPermanent or ❑Temporary Signature ofCcrtified Well Contractor Date
Bysigning this form,/hereby certify that the well(.,)was(were)constricted in accordance with
7.Is this a repair to an existing well: ❑Yes or �No 15A NC'AC'02C.0100 or 15A NCAC 02C.0200 Nrell Construction Standards and that a cn/ry
if dtis is a repair,fill out known well construction information and explain the nature of the of this recornl has been provided io the well jo,rner.
repair under 1121 remarks section or on the back of 1his farut.
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-1 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: 805 ft.
h'or mulriple,vefis list all depths ifdiiferem(example-3@200'aid 2 tt 100') ( ) Submit this GW-1 within 30 days ofavell completion per the following:
10.Static water level below top of casing: 80 24a. For All Wells: Original form I to Division of Water Resources (DWR),
Ifsvoter level it above casing,use"{^ Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
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11. D
Borehole diameter: 6 (in) 24b. For Injection Wells: Copy to WR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:
24c.For Water Su 1 and O cn-Loo Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,,etc.) county environmental healt department of the county where installs
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
3 AIR Permit Program,1611 MSC,Raleigh,NC 27699-161 1
13a.Yield(gpm) Method of test:
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13b.Disinfection type: HTH Amount ;i
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018