GW1-2022-01579_Well Construction - GW1_20220120

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
CHAD HARTNESS "`' .,?C 'r
a �):�. w 14:.WATER'ZONES+ , .
Well Contractor Name FROM TO DESCREPTION
2901 A J AN 2 0 202i 349 ft. 350
ft NCWeGConnaa ft.
y. -�. ,-• E'i'11
CASING for;ulti-.mid:weINb UR'IINER°Ife`licable'1i �,
AIR DRILLING INC ILMETER THICKNESS I MATERIAL
Company Name
0 ft. 142 f4 6I GALV
364836 16,INNER 'T CASING'ORUBING eo'theemalc'lbseilloo :.
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(I.e.U1C,County,State,Variance,etc.) ft ft.
3.Well Use(check well use): ft fa in.
Water Supply Well: '17::SCREEN.
FROM I TO I DIAMETER I SLOT SIZE I THICKNESS I MATERIAL°}
❑Agricultural ❑MunicipaUPublic fL ft, in.
DGeothermal(Heating/Cooling Supply) CIResidential Water Supply(single) ft fa in.
❑IndustriavCommercial ❑Residential Water Supply(shared)
.48!`GROUT_., • . is - <-_ r°- t .,.,
❑Irri ation OWells>100 000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Supply Well: 0 ft 20 tt GROUT POURED
OMonitoring _ ORecovery ft ft.
Injection Well:
DAquifer Recharge ❑Groundwater Remediation ft. fL
❑Aquifer Storage and Recovery ❑Salmi Barrier i 19,SAND/GRAVEL'PACK'ifa "Gable = _ ;
ty FROM TO MATERIAL - EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
OExperimental Technology ❑Subsidence Control fL ft.
[]Geothermal(Closed Loop) ❑Tracer q�i20r'DRILLING,!LOG'attach additional beeti if.necesda
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness,soiurock PAm grain size,etc.
0 IL 132 ft- DIRT
4.Date Well(s)Completed: 12-14-2021 Well ID# 132 fL 365 fL ROCK
5a.Well Location: ft. ft.
BILL MCLAUGHLIN ft. ft.
Facility/Owner Name Facility ID#(if applicable) fL ft.
16311 MOORESVILLE RD,MOORESVILLE,N.C.28115 ft. ft.
Physical Address,City,and Zip ft. ft.
ROWAN 214013 21.REMARKS'
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lot/long is sufficient)
350 37.332 N 800 44.151 W --
12/14/2021
6.Is(are)the well(s): InPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby term that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ItNo 1SA NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a copy
1f this is a repair,fill out known well construction information and explain the nature of the ojthis record has been provided to the well owner.
repair under#21 remarks section or on the back ojthis 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: 365 ft)
For multiple wells list all depths ifdfferenr(example-3@200'and 2(Qa 100') ( Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 40 O 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
It.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 Su 1 and O en-Loo Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmenta ea department o e county where meta
FOR WATER SUPPLY WELLS ONLY: I
24d.For Water Wells Producing over 100,000 GPD:Copy to DWR,CCPCUA
8 AIR Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: HTH Amount: f
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018