GW1-2023-00392_Well Construction - GW1_20230103

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WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only:
1.Well Contractor information:
CHAD HARTNESS 14.WATER ZONES E
Well Contractor Name FROM I DESCRIPTION
2901 A 309 ft. 310 rt.
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells OR LINER(if a licablc)
AIR DRILLING I N C FROM TO DIAMETER THICKNESS Di,ITE""
Q ft. 68 ft. 6 , in. PVC
Company Name
316517 16.INNER CASING OR TUBING cothernial closed-loot))
2,Well Construction Permit#: FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable well c'onstmetion permits(i.e.UIC,County,State,Marrrnrre,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FRtSCREENto DIANIETNIt SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) C1Residential Water Supply(single) ft. ft.
❑industrial/Coniniercial ❑Residential Water Supply(shared) 18.GROUT
❑hrigation ❑Wells> Io0,000.GPD 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 Remedialion
19.SAND/GRAVEL PACK if a licablc
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL I EMPLACEMENT METIIOD
❑AquifcrTest ❑StormwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessar
FROM TO DESCRIPTION color,hardness,soiUrock tyre, rain size,etc.
❑Geothermal(Heating/CoolingRctum) ❑Othcr(cxplainundcrll2! Remarks) 0 ft. eJ$ ft. DIRT
4.Date Well(s)Completed: 6-1 5-2022 Well ID# 58 ft' 325 ft• ROCK
5a.Well Location: ft. ft. ., f "tTM iyvt
PRINCETON HOMES rt. a.
2021
Facility/Owner Name Facility IDN(ifapplienble) ft. ft. I t.
554 KENWAY LOOP,MOORESVILLE,N.C. 28117
Physical Address,City,and Zip ft. ft. ( ; i Ft
IREDELL 4638286830 21•REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latlong is sufficient) rtifl on: - -
35° 37.400 N 80° 54.319 N, -�- - -
�. . 6/15/2022
6.Is(are)the well(s): C1Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this•%arm,1 hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or I'JNo I5A NCAC 02C.0100 or 15A NC iC 02C.i1200 Well Construction Standards and that a copy
if this is a repair,fill out known well construction it formation and explain the nature of the of this recor(I has been provided to the we'll owner.
repair antler 1121 remarks section or on the back of this fora.
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-I is needed. Indicate TOTAL NUMBER of wells (add'Sec Over'in Remarks Box).You may also attach additional pages if accessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 325 (ft.)
For[nuhiple wells list all depths•t/•di(jcrent(trample-3«200'and 2@100� Submit this GW-I within 30 days of well completion per the following:
40 24a. For All Wells: Original form to Division of Water Resources (DWR),
fut nter level is abuse casing,use"+"Static water level below top of casing: (ft')
lnfortnation Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
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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,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
13a.Yield(gpni) 0 Meclloti of test:AI R
Permit Program,1611 MSC,Raleigh,NC 27699-1611
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13b.Disinfection type: HTH Amount: I
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018