GW1-2022-01533_Well Construction - GW1_20220120

WELL CONSTRUCTION RECORD(GW-lbl For Internal Use Only:
1.Well Contractor Information:
CHAD HARTNESS 14.WATER ZONES
DESCRIPTION
WellWell Contractor Name FROM TO
389 IL 390 ft.
2901A
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING for -cased wells OR R i oplligb multi _L f
T C&
AIR DRILLING INC T5 DIAMETER 7 MATERIAL
in.
0 148 ft- 16 PVC
Company Name
245793 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER , I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, I'ariance,etc) ft ft. in.
3.Well Use(check well use): ft ft. i I n.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
OAgricultural OMunicipal/Public ft. in.
DGeothermal(Heating/Cooling Supply) In Residential Water Supply(single) ft. ft. in.
01ndustrial/Commercial 0 Residential Water Supply(shared) 18.GROUT
OIrrigation DWells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0ft 20 ft- GROUT POURED_
OMonitoring DRecovery ft. ft.
Injection Well: ft. ft.
OAquifer Recharge OGroundNvater Remediation
19.SAND/GRAVEL PACK(if applicable)
DAquifer Storage and Recovery ElSalinity Barrier FROM TO MATERIAL I EMPLACEMENTMETHOD
OAquifer Test OStormwater Drainage ft. ft.
DExperimental Technology OSubsidence Control ft. ft.
OGeothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
0 ft 38 1` DIRT
4.Date Well(s)Completed: 1-29-2021 WellIDN 38 fL 405 ft- ROCK
ft. ft.
5a.Well Location:
LAKEMIST HOMES ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft ft.
186 HIDDEN MEADOWS LOT#25,MOORESVILLE,N.C.28117 ft. ft.
Physical Address,City,and Zip ft ft.
IREDELL 4649017133 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) 22
35038.362 N 800 52.538 W
/29/2021
6.Is(are)the well(s): CnPermanent or OTemporary 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: OYes or nNo 15A NCAC 02C.0100 or 15A JVCAC 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 io the well owner.
repair under=21 remarks section or on the back of This form. 23.Site diagram or additional well de I tails:
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 I GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You m'ay also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 405 (ft)
For multiple wells list all depths ifdfferent(example-3@200'and 2@100') Submit this GW-I within 30 days of well completion per the following:
10.Static water level below top of casing: 40 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: Copy to DWR Underground Injection Control (IUC)
Program, 1636 MSC,Raleigh,NC 27649-,1'636
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 ove 100,000 GPD: Copy to DWP,CCPCUA
13a.Yield(gp-) 8 Method of test: AIR Permit Program, 1611 MSC,Raleigh,NC.27699-1611
13b.Disinfection type: HTH Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources j 1 Revised 6-6-2018