GW1-2022-01514_Well Construction - GW1_20220120

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
CHAD HARTNESS h,.,s
R' >'` 9 � 14.WATER ZONES i
�� moo, FROM TO IP DESCRTION
Well Contractor Name e .Q TWIT 509 ft 510
ft. �
�'�':�.', ft ft. t
nrt,
NC Well Contractor Certification Number ^r; pl\ I5.OUTER CASING for multi cased wells OR L[NER if a' licable
AIR DRILLING, INC vn" Ss � j��b' FROM TO DIAMETER THICK
%` NESS MATERIAL
0 ft- 106 ft- 6 'in PVC
Company Name
305538 16:INNER CASING OR TUBING,(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER I 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.
❑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 ft- 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 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 TO DESCRIPTION color,hardness,soiltroek type,grain sae,etc.
0 ft 96 rt. DIRT
4.Date Well(s)Completed. 7-15-2021 Well ID# 96 IL 525 ft ROCK
ft ft.
5a.Well Location:
SPIVEY CONSTRUCTION ft ft.
Facility/Owner Name Facility ID4(if applicable) ft ft.
128 PINE MEADOW LANE, MOORESVILLE,N.C. 28117 ft ft.
ft ft.
Physical Address,City,and Zip
IREDELL 4636051988 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 16
(if well field,one lat/long is sufficient) 21 f� �tifion:
350 33.535 N 800 54.589 W ` _ 7/15/2021
6.Is(are)the well(s): [!]Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,i hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 11No 15A NCAC 02C.0f00 or 15A NC'AC 02C.0200 Well Construction Standards and that a copy
If this it a repair,fill out known well construction information and erplain the native of the of this record has been provider/to the well ox ner.
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: 525 (fL) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if dierent(example-3 tt 2700'and 2@ 100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 1 06 (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
/fwater level is above casing,use"-" j
24b. For Infection Wells:Copy to DWR, Underground Injection Control (IUC)
11.Borehole diameter: 6 (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 departmentof 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
Permit Program, 1611 MSC,Raleigh,iNC 27699-1611
13a.Yield(gpm) 1� Method of test: AIR p
13b.Disinfection type: HTH Amount: !j
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources k Revised 6-6-2018
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