GW1-2022-01512_Well Construction - GW1_20220120

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: ,e
CHAD HARTNESS 14.WATER ZONES
Well Contractor Name a ^ FROM TO I DESCRIPTION
2901 A 0
389 fl 390 ft-
-ft. ft.
NC Well Contractor Certification Number nr r rr��r�l
• 15.OUTER CASING for multi cased wells OR LINER if a licable
AIR DRILLING INC ,,. ��,a,o t` FRDM TO DIAMETER THICIQVFSS MATERIAL
0 ft. 127 ft. 16 in. GALV
Company Name
317177 16.INNER CASING OR TUBING eo therm al closed-loo
2.Well Construction Permit#: FROM I TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.U/C,County,State, Variance,etc) fA ft. in.
3.Well Use(check well use): f, ft. in.
17.
Water Supply Well: FROM SCREENTO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooline Supply) In Residential Water Supply(single) ft. I ft. in.
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Uri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 e• 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 I
❑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,grain size,etc.
0 ft' 117 ft- DIRT
4.Date Well(s)Completed: 7-9-2021 Well iD# 117 It- 405 ft. ROCK
fL ft.
5a.Well Location:
CHRIS FERRELL ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
1171 MIDWAY RD,STATESVILLE,N.C. 28677 fL ft.
Physical Address,City,and Zip ft. ft.
IREDELL 4707836210 21.REMARKS
County Parcel Identification No.WIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 2.Certifi on:
350 51.291 N 800 59.416 W
7/9/2021
6.Is(are)the well(s): 19Permanent or ❑Temporary Signature of Certified Well Contractor - Date
By signing this form,/hereby certify that the ivell(Y)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo i5A NC'AC.'02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
f this is a repair fill out known well construction information and explain the nature of the 0 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 1 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: 405 (ft.)
F'or multiple wells list all depths ifdifferent(example-3@200 and 2@100') Submit this GW-1 within 30 days of well completion per the following:
127 ) 24a. For All Wells: Original form to Division of Water Resources (DWR),
/jx•ater level is above eating,use
ff Static water level below top of casing: (ft* Information Processing Unit, I 1617 MSC,Raleigh,NC 27699-1617
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6 24b. For injection Wells: Copy to DWR, Underground Injection Control (iUC)
11.Borehole diameter: (in.) 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
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over,'100,000 GPD: Copy to DWR,CCPCUA
100 AIR Permit Program, 1611 MSC,Raleigh,NC 27699-1611
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 6-6-2018
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