GW1-2022-01566_Well Construction - GW1_20220120

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WELL CONSTRUCTION RECORD(GW 1)
For Intemal Use Only:
1.Well Contractor Information:
CHAD HARTNESS
_ s e• :1 14.=WATE11;ONES
Well Contractor Name 's v •� L �' FROM TO DESCRIPTION
2901 A °`� 289 ft- 290 ft-
NC Well Contractor Certification Number ft. ft
J gyp!
AIR DRILLING INC o r^ °stj o UTERCA CASING tormalhtased-wells ORLWER ifa livable"'
nrC^ of•.:,,
{y y t DIAMETER THICKNESS MATERIAL
Company Name ks s. 0 ft 75 ft- 6
,f `,,�:,.. I to GALV
353614 >16:'INNER CASING OR TUBING thermal closed400 -
2.Well Construction Permit#: FROM TO DIAMETER I THICKNFSS MATERIAL
List all applicable well construction permits(t.e.UIC,County,State,Variance,e1c.) ft. ft, in,
3.Well Use(check well use): fL ft.
Water Supply Well: 17:SCREEN -
❑Agricultural ❑MunicipaVPublic ft. ft.FROM TO DIAMETER SLOT SIZE THtCIQYFSS -MATERIAL
❑Geothermal(Heating/Cooling Supply) L'IResidential Water Supply(single) i°.
❑IndustriaVCommeroial ft. ft, in,
❑Residential Water Supply(shared)
❑Irri ation 18:GROUT
❑Wells>100,000 GPD FROM TO MATERIAL AM
Non-Water Supply Well: 0 ft. 20 ft EMPLACEMENT METHOD& OUNTGROUT POURED
❑Monitoring ❑Recovery tL
Injection Well: ft.
❑Aquifer Recharge ❑Groundwater Remediation % ft
❑Aquifer Storage and Recovery ❑Salinity Barrier FL9 SAND/GRAVEL PACK ifa Ilceble
FROM TO LA
❑Aquifer Test ❑Stormwater Drainage fL ft. MATERIAL EMP CEMENTMEI'HOD
❑Experimental Technology ❑Subsidence Control fL ft.
❑Geothermal(Closed Loop) ❑Tracer 20'DRILLING'LOG attach additional sheets if necessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) DE
FROM TO SCRIPTION color hardness,soiltrec a in size,etc.
4,Date Well(s)Completed: 11-30-2021 0 fL 65 fa DIRT
Well ID#
65 IL 305 ft, ROCK
Sa.Well Location: ft. ft.
ERIN OLIVER ft.tRMM
Facility/Owner Name Facility IDb(if applicable) ft.
620 PARKS RD, WOODLEAF, N.C. 27054 ft,
Physical Address,City,and Zip ft.
ROWAN 818080 2L;REMA
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degreeshninutes/secoads or decimal degrees:
(if well field,one lat/long is sufficient)
35°45.198 N 80035.306 `c rtiec
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11/30/2021
6.Is(are)the well(s): MPermanent 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 MNo /3A NCAC 02C.0100 or 1SA NCAC 01C.0200 Well Construction Standards and/hat 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#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:
9.Total well depth below land surface: 305 24.SUBMITTAL INSTRUCTIONS(ft.)
For multiple wells list all depths ifdryferent(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: 50 (ft) 249. For All Wells: Original form to,Division of Water Resources (DWR),
lfwater level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in,) 24b.For Infection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:
(i.e.auger,rotary,cable,direct push,etc.) 24c.For Water Su l and O en-Lo I
__p-on Geothermal Return Wells:Copy to the
county environmenta eat epartment o e county where msta
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells Producing over 100 000 GPD• Copy to DWR,CCPCUA
13a.Yield(gpm) 15 Method of test: AIR Permit Program,1611 MSC,Raleigh,NC 27 909-161 I
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13b.Disinfection type: HTH Amount:
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Form GW-1 �
North Carolina Department of Environmental Quality-Division of Water Resources Revised 6.6-2018