GW1-2022-01527_Well Construction - GW1_20220120

WELL CONSTRUCTION RECORD(GVY For Internal Use Only: F `
1.Well Contractor Information: ��tNv {�,�y�
CHAD HARTNESS o �� 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2901A 589 ft 590 fLI
a ft. ft. i
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR L1NER if a livable
AIR DRILLING INC FROM TO DIAMETER THICKNESS MATERIAL
0 ft 65 ft- 6 in. PVC
Company Name
16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: 312827 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. ft1 in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic ft. ft in.
❑Geothermal(Heating/Cooling Supply) In Residential Water Supply(single) ft. ft. in.
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 fL GROUT POURED
❑Monitoring ❑Recovery ft ft.
Injection Well:
ft ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑StonnwaterDrainage ft ft
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal FROM TO DESCRIPTION color,hardness,soiUwck rain size,etc.
(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
0 fL 55 ft- DIRT
4.Date Well(s)Completed: 03-22-2021 Well ID# 55 ft 605 ft- ROCK
5a.Well Location: ft. ft.
DERECK OSBORNE BULERS ft ft.
Facility/Owner Name Facility ID#(if applicable) ft ft
762 BROOKHAVEN RD,STATESVILLE,N.C. 28677 ft. ft
Physical Address,City,and Zip ft ft.
IREDELL 4811147655 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) ertifr •on:
350 58.169 N 800 59.220 W !' � , � -
3/22/2021
6.Is(are)the well(s): OPermanent 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 (INo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,Jill 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: 605 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdierent(example-3@200'and 2@100')
10.Static water level below top of casing 65 (fL) 24a. For All Wells: Original form to.Division of Water Resources (DWR),
Information Processing Unit,1617 MS Raleigh,NC 27699-1617
1f water level is above casing,use
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-Lop 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) 20 Method of test AIR Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount:
i
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018