GW1-2023-00387_Well Construction - GW1_20230103

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WELL CONSTRUCTION RECORD (GW-i) For Internal Use Only:
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1.Well Contractor Information:
CHAD HARTNESS 14.WATER ZONES it -
Well Contractor Name FROM TO DFSCRIPTION
2901 A 449 ft- 450 ft•
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased iWl,l OR LINER(if a licable)
AIR DRILLING I N C FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 67 rt. 6 I in. PVC
317578 16.INNER CASING OR TUBING eotherntat closed-loop)'
2.Well Construction Permit#: FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC County,State,Variance•etc.) ft. ft. j in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN '
FROM .1.0 DIAMETER SLOT slz,E THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) L9Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft- GROUT POURED
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
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❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StonnwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control R. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.•DRILLING LOG attach additional sheets if necessar
❑Gcotlternlal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soilfrock type,grain size,etc.
0 ft. 96 ft- DIRT
4.Dale Well(s)Completed: 7-12-2022 Well ID# 96 ft. 465 ft- ROCK
5a.Well Location: ft. ft.
LAKEMIST HOMES fL f`. _
Facility/Owner Name Facility ID#(if applicable) ft. ft.
129 RYLEIGH DAN, MOORESVILLE,N.C. 28115 ft. ft. k ''�;�;-�•' -v' �'�W
Physical Address,City,and Zip ft. ft. n 21,23
IREDELL 4654685676 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) 2. Crtif Lion' '
350 29.954 N 800 49.603 W 7/12/2022
6.Is(are)the well(s): OPermanent or ❑Temporary Signature ofCcrtifted Well Contractor Dale
By signing this form,1 hereby certifi,that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or InNo I5A NC•IC 02C.0/00 or 15A NCAC 02C.0200 Nell Construction Standards and that a copy
tlThis is a repair,•fill oat known well cortsa•uction ittforntaiion a td explain the nattve of the of this record has been provided to the well owner.
repair under#21 rcnmrks 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 construction info
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of"vells (add'Sce Over'in Remarks Box).You imay also attach additional pages ifnccessary.
drilled: 24.SUBMITTAL INSTRUCTIONS'
9.Total well depth below land surface: 465 (ft.) '
Fornudtiple wells list all depths/fdi�ercnt(eratrple-3 a 200'atd2 tt!00') Submit this GW-I within 30 days of"well completion per the following:
Q0 24a. For All Wells: Original form;to Division of Water Resources (DWR),
9"n Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
!f •nter fete%is abate caring,use"+"
11.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 Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotury,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
Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 30 Method of test:AIR
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13b.Disinfection type: H I H Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6r2018
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