GW1-2022-01506_Well Construction - GW1_20220120

WELL CONSTRUCTION RECORD(GW-D n, For Internal Use Only:
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1.Well Contractor Information:
CHAD HARTNESS nor, 14.WATER ZONES
e Well Contractor Name � � \\\�'�
FROM TO
PC rc\CA f 489 ft- 490
2901 A e Z
f4 DESCRIPTION
.�y0� ft. ft.
r^
NC Well Contractor Certification Number
15.OUTER CASING for multi-sed wells OR LINER if a licable
AIR DRILLING INC ia�,'�c �� FROM TO DIAMETER ! THICKNESS MATERIAL
0 ft ,07 1- 6 in. I I PVC
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 317620 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. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft in.
❑lndustriaUCommercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 20 fL 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 I EMPLACEMENT METHOD
❑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) FROM I TO DESCRIPTION color,hardness,soil/mck type,grain sae,etc.
0 It- 97 ft DIRT
4.Date Well(s)Completed: 8-11-2021 Well ID# 97 fL 505 ft- ROCK
ft. ft.
5a.Well Location:
WILLIAM RASH ft. ``
Facility/Owner Name Facility iDk(ifapplicable) ft. ft.
135 WILLIFORD RD,MOORESVILLE,N.C. 28115 ft. `t.
Physical Address,City,and Zip ft. ft.
IREDELL 4676311838 21.REMARKS
County Parcel Identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: IF
(if well field,one Iatilong is sufficient) ertif lion:
350 33.200 N 800 46.165 WV K
8/11/2021
6.Is(are)the well(s): OPermanent or ❑Temporary Signature ofCertified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.is this a repair to an existing well: ❑Yes or (INo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
if dti.s is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well aHmer.
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 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: 505 (ft)
S
For multiple wells list all depths ifdi tterent(example-3 200'and 1@100') Submit this GW-1 within 30 days of well completion per the following:
40 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
If water level is above casing,use "
I I.Borehole diameter: 6 (in,) 24b. For Injection Wells: Copy to DWR, Underground Injection Control (TUC)
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(gpm) 3 Method of test: AIR Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018