GW1-2022-01534_Well Construction - GW1_20220120

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: i
1.Well Contractor Information:
CHAD HARTNESS 'V 14.WATER ZONES
a;^-.�- :FROM TO DESCRIPTION
Well Contractor Name A��• ^ 489 ft' 490 ft.
2901 A r
O� : fL ft
NC Well Contractor Certification Number ' c
15.OUTER CASING for multi-cased wells OR LINER if a licable
AIR DRILLING INC. z. �* C1 FROM TO DIAMETER THICKNESS MATERIAL
1� "` o° 0 ft 70 ft. 6 in. PVC
Company Name
.. a 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 245796 ,;;' FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,NQhiance,etc.) ft ft in.
3.Well Use(check well use): ft ft in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) In Residential Water Supply(single) ft. ft. in.
❑Industrial/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 a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO MATERIAL! EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage fL IL
OExperimental 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 I TO DESCRIPTION color,hardness,soil/rock type,grain sae,etc.
0 IL 60 ft- DIRT
4.Date Well(s)Completed: 2-8-2021 Well ID# 60 fL 505 ft- ROCK
59.Well Location: ft ft.
LAKEMIST HOMES fL ft
Facility/Owner Name Facility ID#(if applicable) ft ft.
170 HIDDEN MEADOWS LOT#28, MOORESVILLE,N.C.28117 rt ft.
Physical Address,City,and Zip ft ft.
I REDELL 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) �tifiea'
35n 38.695 N 80n 52.536 W �`2/8/2021
6.Is(are)the well(s): InPermanent or ❑Temporary Signature of Certified Well Contractor Date
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By signing this form,!hereby certify that fhe',well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MN0 15A NCAC 02C.0100 or 15A NCAC 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 921 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: 505 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if dierent(example-3@200'and 2@/00')
50 24a. For All Wells: Original form jto.Division of Water Resources (DWR),
10.Static water level below top of casing: (ft) Information Processing Unit,1617 MSC,,Raleigh,NC 27699-1617
6 water level it 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
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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
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 8 Method of test- AIR
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount:
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018