GW1-2023-00367_Well Construction - GW1_20230103

i
WI+,I,I,CONS`I'RUC'1'ION ItI+,CORD GW-1 �
]nor)n1el'flol Use Only:
I.1Vell Contractor 1111.01.nuition:
CHAD HARTNESS
Well Conutlutor Nnmc 14.WATER''/,ONES
FROM 'I'0 OESCRII'TION
2901 A 95 11' 96 n,
NC Well Contractor Certification Number 971 f6 972 ft. I i —ESS ---
AIR DRILLING INC 15.OUTER CASING(formillti-cosediJelis)ORLINER ira ,licnhlc
GRO\I TO DL1NIfiTCR1 TIIICKN �I,\TIsR1A1.
Company Name 0 ft, 64 ff. 8 I Ian. GALV
2.Well Construction permit#; 16,INNER CASING OR TU11)NG cothermul closed-loo,)
Lill
FROM T'0 1)JAM R•1'ER' —THICKNESS
\l:\'ITiRL\L
till upplic'abh•weNe•onsntrcda,permits(l.c•.O/C,Cornay,Slnlc, Variance.etc•.)
fL ft. in.
3.Well Use(check 11,e11 use): ft, ft. in,
11'alo Supply 1Vell: 17,SCREEN
LlAgriculu°`tl MMunicipal/Public PRoJI TO prn.rrn.rl:u S1,o'rS1%6: THICKNESS riATr•.RiAi.
L1Gcolhermal(Healing/Conlin g Supply) ❑Residential Water Supply sin'le ft. ft. in.. —
I.Ilndusu•ial/Commercial Il• ft. in. -----
Ll Residential Water Supply(shared)
❑Irri)!alioit IS,GROUT
❑We]is> I00,000GPD rr(o�l I'o nlnr'ERL\t. t:rn'LAcl:anaNl'nn;TnonsAn)uuNT
Non-1Vatcr Supph'Wcll: 0 f' 62 f'' GROUT POURED
flMonitori°g ❑Recovery
lnjectipn Well: —ft,
0Aquifer Recharge ❑Groundwater Rcmcdiation -
EIAquifcr Storage and Recovery ❑Snlinity Barriel- 19.SAND/GRAVEL PACK if Lilicablc)
moat ro mrrcrhltlnl. EMPLncP.�IrcN'rmu:ruon
I"lAquifer'I'csl ❑Biota»vatcr Drainage ------
❑Experin)eual'l'cclluol°gY ❑Subsidence Control
E1GcOthemial(Closed Loop) ❑T raccr 20.DRILLING 1, attach additional sheets if necessary)
❑(Seothermal 0.1cating/Cooling Return) ❑Other(explain under#2l Remarks) 1711011 To DESCRIrTfON war,hanlffcss,seiuracir t ro,•rain sire,ea•.)
f`' 54 f' DIRT
4.Ualc 1Ve11(s)Com 12-21-22 0 pleted: Well IM 54 fl• 1005 f' ROCK
5a.Well Location: ft. fl.
IREDELL WATER ft. -
Pacilily/OwnerNfmne Pacility11380fapplicable) It• ft,
482 NIXON RD,STATESVILLE,N.C. 28677 f1• ft. —
Physical A(Idress,City,and Zip _ft. ft. ---
IREDELL Infrril,2'•.a2­rl (-nr
21.REMARKS e1 v�
(0001) 137 Parcel Identification No,(PIN)
51).Latilude and longitude in degreeshninuies/seconds o'decimal degrees:
(il'u•cll licld,une Lnilunt;is suliicicnl) /�
35° 50.541 80° 62.419 22.{et'titljtin)t: u
Cr.ISOM)the well(s): 1_IPern)anent of- ❑Temporary Signature of Cotiriccl Well Contractor 12/21/2022Date
7,Is this a repair to an existing well: l3ysign/ng ihi.sfar iol,/hereby cert/(i•dial the well(.$)wwas(were)colistrucred in accordhnlce with
Oyes or nNo /5.4 A'G:•tC OlC.(//00 nr(Sat r\'G:dL'U3C,(1?(1(I IYe!!Conatrrrcr/nn S'tanr/nrrG'nnr/attar rr ropr
Ifrhis lr a relmir. ill our known well c01INI"(W1/011 in%r•mation and evplaln the nature of the rf this record has been proMded h,the well owner,IT/Mir antler 112/remarks s ec tlnn ar on the hnc•k of this fru nr,
23.Site diagram or additional hell details:
S.For Geoprohe/DPT 0r Closed-Loop Geothermal Wells having the same You may use the back of*this page to provide additional \veil construction info
Construction,only I GW-1 is needed. Indicate TOTAL.NUMBER ol'wells (add'See Over'in Remarks Box).You stay also attach additional pages it'ceessafy.
dri l led; -
1005 24,SUB51IT•I AL INSTRUCTIONS
').'1'olal well depth below land surface: (ft.)
For nrulriple wells list all depd,s//'dvlbrclrr(rsanrpfe-3�?20(1'and l rr,/00') Subn)il this GW-I within 30 clays or well completion per the follolving:
10.Static water level below top of casing: 40 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWIZ).
/Jlvaler level is abort ra,rirrg,use ,f^ Information processing Unit, 1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 8 24b.For Injection Wells: Copy to D1VR, Underground lnjcction Control (IU(:)
12.11'ell construction method: Program, 1636 MSC,Raleigh,NC 27699-1636
(i.e.auger,rouu•y,cable,direct push,etc.) 24e.For\Valet'Supply find 0 ell-Loop Geothermal Return Wells•Copy to the
eouuly envu'onn)ental health(Icpulln'lent of the aunty lvticre installed
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells producing over 100,000 GPD• Copy to DWR,C'CI'C'LJA
13a.Yield(gpm) 250 Method of test: AIR Permit Program, till I MSC,Raleigh,NC 27699-1611
131).Disinfection type: HTH Amount:
l°tan(sVJ-I North Carolina Depimmeol of linvironmental Quality-Division of Watcr Resources
Revised G-G;'01S