GW1-2023-00369_Well Construction - GW1_20230103

� I WELL CONSTRUCTION RECORD (GW 1) For Internal Use Only:
11
1.Well Contractor Information: p '
CHAD HARTNES 14:WATER7.ONES y
WellContradtorName FRUM I UBscRiPTION
2901 A 229 ft• 230
ft. ft.
NC Well Contractor Certification Number
AIR DRILLING I N C 15.OUTER CASING for ntulti-caseil wells)OR LINER(if a licnble)
FROM TO DIAMETER THICKNESS MATERIAL
Company Nano
p ft. 79 ft. 6 I in. GALV
2022-0320 16.INNER CASING OR TUBING 'eothermal closed-loop)-
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable arl/construction permits(i.e.U1C,County,State,llat•iance,etc.)
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE •1'IIICKNESS MATERIAL
❑Agricultural ❑MunicipaVPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) InResidential Water Supply(single)
ft. ft. in.
0 Industrial/Com mercial ❑Residential Water Supply(sllarcd)
18.CROUT-
❑Irri ation ❑We]Is>100,000 GPD FROM TO MATERIAL F.MI'L.\CEMENT METIIUD&AMOUNT
Non-Water Supply Well: 0 ft' 20 ft- GROUT POURED
❑Monitoring ❑Recovery ft. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation ft. ft.
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL rNIPLACCAIENTMETIfOD
[]Aquifer Test ❑StormwaterDrainage
❑Experimental Technology ❑Subsidence Control ft. ft.
❑GCotltemtal(Closed Loop) ❑Tracer 20.DRILLING LOG attach addition:il'sheets if necessar•
❑Geothermal(lleating/Cooling Return) ❑Other(explain under#2l Rcmarks) FROM TO DESCRIPTION(color,hardness,soilkock lv e,gmin size,etc.
0 f`• 69 f'• DIRT
4.Date Weu(s)Completed: 09-13-2022 Well ID# 69 ft- 1245 ft ROCK
5a.Well Location:
KENT GREGORY ft. ft.
Facility/Owner Name Facility iD#(ifapplieable) ft.
168 BOWLES FARM RD, STATESVILLE,N.C. 28677 n. ft. 7z:�'
Physical Address,City,and Zip ft. ft. Q 0- r
IREDELL 4718278616 21.REMARKS 90
' •-
Count' Parcel Identification No. PIN ':'• '
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
�D4 tQrDOG
(ifwell field,one Iatllong is sufficient) rtific on:
35° 53.910 N 80° 59.029 r, /13/2022
6.Is(arc)the well(s): InPermanent or ❑Temporary Signature of Cenified Well Contractor Dale
By signing this form,1 hereby cerlV.i'that the well(s)was(here)catsro•ucted in accordmlce with
7.Is this a repair to an existing well: ❑Yes or [nNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Iite//Construction Standards and that a copy
/J this is a repair•fill out known well construction information and explain the nature of the olthis•record has been provided to the wel/opener.
repair-under#21 reutarks section or on lire 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 I OW-1 is heeded. Indicate TOTAL NUMBER of wells (add'Sce Over'in Rcmarks Box).You may also attach additional pages ifnecessary.
drilled:
24.SUBMITTAL INSTRUCTIONS,
9.Total well depth below land surface: 245 ft.)For nuthiple bells list all depths ifdi(jerent(example-3 a•200'and2@100') ( Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below lop of casing: 50 24a. For All Wells: Original form ,to Division of Water Resources (DWR),
ywater level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6 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,clef county environmental health department of the county where installed
P
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:
AIR Permit Program, I61 1 MSC,Raleigh,NC,27699-161 I
13b.Disinfection type: HTH Amount:
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018