GW1-2022-06471_Well Construction - GW1_20220503

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Chad Hartness 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 0 ft. 700 ft. Trace
2901 A
700 it, 825 tt- 1 GPM
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
HickoryWell Drilling Co. , Inc. FROM TO DIAMFTKR 'rHiCKNESS MATERIAL
g 0 ft. 180 ft• 6 1/41n' SR211 1PVC
Company Name 16,INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: Burke 19637 FROM TO DIAMETER TFIICKNF.SS MATERIAL
List all applicable well construction permits(i.e.UIC.Cmtnty,State, Variance,eirJ
tt, ft. in.
ft.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public o ft, ft. 1n•
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. tr. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Ir[l AtlOn FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft' Bentonit Poured from To
Monitoring ORecovery
Injection Well: ft. ft.
Aquifer Recharge Io'.Groundwater Remediation 19.SANDIGRAVEL PACK if applicable)
Aquifer Storage and Recovery EISalinity Barrier IROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test oStorniwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothenmal(Closed Loop) Tracer 2o.DRILLING LOG attach additional she if necess
FROM TO DESCRIPTION color hardacrt soiltrock rain 0ao etc.
Geothermal(HeatinglCoolin Return) rJOther(explain tinder021 Remarks) 0 ft. 74 ff Dirt.L'oo e
4.Date Well(s)Completed: 03/29/2022Weulm 74 ft' 825 ff Granite Bed
ft ft.
5a.Well Location:
ft. ft.
Roy and Michele Caws
ft. ft.
Facility/Owner Name FacilityiD#(if applicable)PPlicable)
ft.
3824 Mountain Vista Dr. , Morganton, NC r-
Physical Address,City,and Zip
55 tr. ft. 0
Burke 2722769358 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) rtifiea n:
35.72100 N 81.60267 W 24A 4/28/2022
6.Is(are)the wcll(s)0Pcrmanent or ®ITemporary
Signature of Certified Well Contractor Date
By signing this form,1 hereby cerrifi,•that the Hr/!(.r)was(were)constructed In accordance
7.is this a repair to an existing well: r3Yes o1xoNo will,ISA NCAC 02C.0160 or 15A NCAC 02C:0200 Well Construction Standards and that a
If this is a repair,,/)//our known well construction 1pftrmation and explain the nature of the COPY of this record has been provided to the well owner.
repair tender#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 site details or well
construction,only 1 GW-1 is needed, Indicate TOTAL NUMBER of wells
construction details. You may also attach additional pages if necessary.
drilled: N/A SUBMiTTALiNSTRUCTiONS
9.Total well depth below land surface: 925 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For mulliple wells list all depths if different(example-3Ca3200'and 2[i✓o100') construction to the following:
10.Static water level below top of casing:
209 (Af ter 20 Huts).) Division of Water Resources,Information Processing Unit,
If tinter level Is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Rotary Air Drilled above, also submit one copy of this form within 30 days of completion of well
12,Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1 Method of test: By Air Test 24c.For Water SUDDIV&Injection Wells: In addition to sending the form to
and Fill the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Chl. Grans.Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1
North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016