GW1-2022-01542_Well Construction - GW1_20220120

WELL CONSTRUCTION RECORD GW-1 �' For Internal Use Only:
1.Well Contractor Information:
CHAD HARTNESS ��*000, 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name �a re��\�� 289 ft 290 ft
2901A �or ft. ft.
NC Well Contractor Certification Number , 15.OUTER CASING for multi cased wells OR LINER if a licable
AIR DRILLING INC ��'Jsl` FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft 103 ft 6 !in' PVC
EH2O-04248 16.INNER CASING ORTUBING eothermalclosed-loo
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well 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 SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic R. ft. in.
❑Geothermal(Heating/Cooling Supply) In Residential Water Supply(single) ft. ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑irrl atlon ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 l" GROUT POURED
❑Monitoring ❑Recovery ft ft.
Injection Well-
it. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 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 DESCRIPTION color,hardness,soil/rock type, 'n sae,etc.
0 ft 93 ft. DIRT
4.Date Well(s)Completed: 7-20-2021 Well ID# 93 ft. 305 ft- ROCK
5a.Well Location: ft. ft.
ASHER HOMES ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft ft.
7190 WINDY RIDGE DR,IRON STATION,N,C. 28080 ft ft
Physical Address,City,and Zip ft. ft
LI NCOLN 88042 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) tific n:
350 28.551 N 81023.098 W 7/20/2021
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby ceritfy 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,fill out known well construction information and explain the native 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-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: 305 (ft.)
for multiple wells list all depths ifdiereni(erample-3 a 200'and 2 a 100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 50 (fL) 24s. 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 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(gpm) 10 Method of test: AIR
Permit Program, 1611 MSC,Raleigh,NC 27699-161 1
13b.Disinfection type: HTH Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018