GW1-2022-01511_Well Construction - GW1_20220120

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
CHAD HARTNESS _ t„ f�9 14.WATER ZONES s
y Well Contractor Name _ d v FROM TO DESCRIPTION'
�' �.► ;
';�3J ,1 669 ft- 670 ft.
2901A n 1 (�. © 'tQ(t• ft. ft.
NC Well Contractor Certification Number ACQ D I�\1
cS�Ct��6 15.OUTER CASING for multi cased wells OR LINER if a lit able
AIR DRILLING INC tt�l�V.)01VQ � FROM TO DIAMETER: THICKNESS MATERIAL
-�S 0 fL 72 ft- 6 !in. PVC
Company Name ,r j'. D\' `v J
16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: 237267 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft ft.
3.Well Use(check well use): ft. ft. in.
Rater Supply Well: 17.SCREEN
FROM TO DIAMETER 'SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) [)Residential Water Supply(single) ft ft. in.
❑Industrial/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 ft. ft.
Injection Well:
ft ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage fL 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,soil/rock e,gnin size,etc.
0 fL 62 It- DIRT
4.Date Well(s)Completed: 8-2-2021 Well ID# 62 ft 685 ft- ROCK
5a.Well Location: ft. ft.
PEACHTREE RESIDENTIAL ft. ft.
Facility/Owner Name Facility IDk(ifapplicable) ft. ft.
128 BROAD BIRCH RD, DAVIDSON,N.C. 28036 ft ft.
Physical Address,City,and Zip ft ft.
IREDELL 4664866601 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) Arti
fi on:
350 30.482 N 800 47.957 W 8/2/2021
6.Is(are)the well(s): Permanent or ❑Temporary Signature of Certified 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 In No 15A NCAC 02C A100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under 921 remarks section or on the back of ihis 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-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: 685 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if diereni(example-3 a 00'and 2 rt 100')
60 24a. For All Wells: Original form ito Division of Water Resources (DWR),
Ifffw ater level is above casing,use"+Static water level below top of casing: (ft) Information Processing Unit,1617 MSC,IRaleigh,NC 27699-1617
w "
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
I
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) 15 Method of test AIR Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: j
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018