GW1-2022-01521_Well Construction - GW1_20220120

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
CHAD HARTNESS a v,o. 14.WATER ZONES
Well Contractor Name �j l FROM
ft' O fL DESCRIPTION
2502901A
NC Well Contractor Certification Number
AIR DRILLING INC
t W,'v' �J FROMUTER CTOSING form DIAMETER
IAME ER111
Is O CKNESS NER if a ItMATERIAL
0 ft 61 ft. 6 Am
PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: 319065 FROM TO DIAMETER THICKNESS MATERIAL
List aU applicable me/l 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 i SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft in.
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft' GROUT
❑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 I TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 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 DESCRrwrloN color,hardness,soil/rockrein size,etc.
)0 ft 51 ft• DIRT
4.Date Well(s)Completed: 7-6-21 Well ID# 51 ft 265 ft- ROCK
5a.Well Location: ft R.
MICHAEL KILBY ft ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
248 ABSHER FARM LOOP, STATESVILLE,N.C. 28677 ft. ft.
Physical Address,City,and Zip
ft ft.
IREDELL 4715966170 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(350 field,one latllong is sufficient) j°�� ertifi ton: T �
35 48.421 80057.269
NW (! �-- -7/6/2021
6.Is(are)the well(s): nPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,/hereby cert6fy that the'well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or QNo 15A NCAC 02C.0100 or 15A NC'AC 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=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: 265 (ft) Submit this GW-i within 30 days of well completion per the following:
For multiple wells list all depths ifdiereni(example-3@200'and 2@ioo') y p p g'
40 24a. For All Wells: Original form Ito Division of Water Resources (DWR),
10.Static water level below top of casing: (ft) Information Processing Unit, 1617 MSC,'Raleigh,NC 27699-1617
ljNater level is above casing,use"-"
6 24b. For Infection Wells: Copy to DWR,Underground Injection Control(1UC)
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
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing ov'r 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) 20 Method of test: AIR
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount:
Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018