GW1-2023-00385_Well Construction - GW1_20230103

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WELL CONSTRUCTION•RECORD (GW-1) For Internal Use Only:
I.Well Contractor Information:
CHAD HARTNESS
'14.'WATERZONES. ,.
Wcll Contractor Name FROM to DESCRIPTION
2901 A 409 ft- 410 ft-
ft.NC Well Contractor Certification Number ft. I _I
AIR DRILLING I N C IS.-OUTER CASING(for multi-casedlwclls OR LINER if a licable)
FRO\I TO DIAMETER THICKNESSI MATERIAL
Company Name ft. 91 ft. 6 I in. PVC
317594 16.INNER-CASING-OR TUBING eothermal closed-loo -
2.Well Construction Permit#: FROM TO I DIAMETER. I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. I in.
3.Well Use(check well use): ft. ft. ! in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. n. in.
❑Geothernial(Heating/Cooling Supply) 15Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) -1s:GROUT.
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft• GROUT POURED
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEIIIENTMETHOD
❑Aquifer Test ❑StormwaterDrainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Gcothcnnal(Hcating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hunlncss,soillrock tv e, rain size,etc.
0 81 rt• "DIRT --
4.Date Well(s)Completed: 7-1 5-2022 Well ID# 81 ft' 425 ft' ROCK
5a.Well Location: ft. ft,
LAKEMIST HOMES ft. ft. -� •�.
Facility/Owner Name Facility ID#(ifapplicable) f a "<•t > 'u• -- 4--
125 RYLEIGH DAN RD, MOORESVILLE,N.C. 28117 ft. ft-] J A N p 5, 2023
Physical Address,City,and Zip tt. ft. 1 hr t
IREDELL 4654686551 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22. rertifi lion: —
350 31.587 N 80- 49.330 W `�' - 7/15/2022
6.Is(arc)the wcll(s): C1Permancnt or ❑Temporary Signature of Certified Well Contractor ` Date
Bvsigning this form,I hereby certi i,thai die wells)was(were)coiistructecl in accordance with
7.Is this a repair to an existing well: ❑Yes or CINo I9A NCAC 02C.0100 or I5A NCAC 01C.0200(Pell Construction Standards and that a copy
ff this is a repair,fill out kni7wn well construction Information and arplain the nature of the of this record has been provided to the well Iowner.
repair alder#21 remarks section or ou 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-I is needed. Indicate TOTAL NUMBER of wells (add'See Ovice in Remarks Box).You may also attach additional pages if necessary.
drilled:
24.SUBMITTAL INSTRUCTIONS;
9.Total well depth below land surface: 425 ft.)For multiple ivel/s list all depths ifdiQerent(erautple-3 r@200'and 2@1001 ( Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 50 (ft 24a. For All Wells: Original form ,to Division of Water Resources (DWR),
If water level is above casing,use"+" ) Information Processing Unit,1617 MSC,Ralcigh,;NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells:Copy to DWR, Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699=1636
i..Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.u,auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
20 Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:AIR
13b.Disinfection type: HTH Amount:
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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