GW1-2022-01529_Well Construction - GW1_20220120

I
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: i
1.Well Contractor Information:
CHAD HARTNESS ntnin [4
��`s� bO`` ��.:''14.WATER ZONES
�+' b .,r•�,+ FROM TO DESCRH'TION s
Well Contractor Name �� Cy • : 889 $90
?ro r:'^ ft ft.
2901 A P�� 'J
`'� `' fL ft.
NC Well Contractor Certification Number .r '.t;."� 15.OUTER CASING for mulfi-cased wells OR IN if a licable
AIR DRILLING INC r„'`v�'J` FROM TO DIAMETER THICKNESS MATERIAL
0 IL 194 ft. 6 in. GALV
Company Name +'
16.INNER CASING OR TUBING eothermal closed-too
2.Well Construction Permit#: 309635 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Stale, Variance,etc.) fL ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) IlResidential Water Supply(single) ft. fL in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 IL 20 ft- GROUT POURED
❑Monitoring ❑Recovery R. ft.
Injection Well:
ft. fL
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage fL IL
❑Experimental Technology ❑Subsidence Control R. 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 c(ilor,hardness,soil/rock e,grain sae,eta)
0 IL 184 ft- DIRT i
4.Date Well(s)Completed: 4-5-2021 Well ID# 184 iL 905 ft- ROCK
5a.Well Location: R ft.
BRYAN CLODFELTER ft. fL
Facility/Owner Name Facility ID#(if applicable) fL ft.
223 KNOX FARM RD,STATESVILLE,N.C. 28677 fL ft.
Physical Address,City,and Zip fL ft.
IREDELL 4773902135 21•REMARKS
County Parcel Identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one latllong is sufficient) a fica '
350 44.387 N 800 45.227 w 4%6/2021
6.Is(are)the well(s): I'JPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,i hereby certify that the ivell(s)was(were)constructed in accordance with
7-Is this a repair to an existing well: ❑Yes or ItNo 15A NCAC 02C.0100 or 15A NC'AC 02C A200 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 421 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: 905 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2 a l00')
10 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft) Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
If 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-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 over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gP m) 5 Method of test- AIR Permit Program,1611 MSC,Raleigh,NCt27699-1611
13b.Disinfection type: HTH Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources I Revised 6-6-2018