GW1-2023-00393_Well Construction - GW1_20230103

WELL CONSTRUCTION RECORD (GW 1) Pot Internal Use Only:
I.Well Contractor Information:
CHAD HARTNESS
14.WATER ONES,
Well Contractor Name FRO31 TO DESCRIPTION
2901 A 209 ft- 210 ft. 6 i
NC Well Contractor Cerlification Number ft•
AIR DRILLING I N C .15.OUTER CASING for multi-cased wells OR LINER if a licable
FROM TO DIAMETERI TI IICKNESS MATERIAL
Company Name 0 ft• 72 ft- 6 iin. PVC
2. 321010 16.INNER CASING OR TUBING cothermal closed-loo
Li Well Construction Permit#; FROM TO DIAMETER THICKNESS p1ATERI,\L
List all applicable urll rnns'Iroc'tion perutics(i.e.UIC,County,Slate,Var•iarice, ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
❑Agricultural FROM TO DIAME'rER SI.O'r7EMPLACENIENTMrTlion
IICKNESS MATERIAL
b ❑MunicipaVPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) In Residential Water Supply(single)
ft. ft. In.
❑Ind ustrial/Comma•cial ❑Residential Water Supply(shared)
lS.GROUT
❑IITi�ati0n ❑WClls> 'An Ann GPD FROM TO INIATMAL S,\MOUNT
Non-Water Supply Well: 0 rt. 20 ft• GROUT POURED
❑Monitoring ❑Recovery ft. ft.
Injection Well:
❑A uifer Recharge
q g ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable❑Aquifer Storage and Recovery ❑Salinity Barrier FROJI TO MATERIAL EM PLACEM ENT METHOD
❑Aquifer Test ❑Stonnwater Drainage ft. tt.
❑[experimental Technology ❑Subsidence Control ft. ft.
❑Gcothennal(Closed Loop) ❑Tracer -20.DRILLING LOG attach additional sheets if necessar y
❑Gcothennal(Ilcaling/Cooling Return) ❑Other(explain under 1121 Remarks) FROM TO DESCRIPTION color,hardness,solVrack Iv rc,grain size,cic.
0 ft- 62 ft- DIRT
4.Date Wcll(s)Completed: 06-16-2022 Well ID# 62 ft- 225 ft, ROCK
Sa.Well Location:
PRINCETON HOMES ft. rt.
Facility/Owner Name Facility IDB(ifapplicable) ft.
558 KENWAY LOOP,MOORESVILLE,N.C. 28117 ft. ft.
Physical Address,City,and Zip A. ft. ^N S '-023
IREDELL 4638287742 21.REMARKS y;a,.ti..­.3'.?.' ilnfi
County Parcel ldentifcaiion No.(PIN) r - Da JLl5,0 G
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) -
tifica n:
350 37.388 N 800 54.310 N _
.,6/16/2022
6.ls(arc)the wcll(s): IJPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby cert fv that die we//(s)was(were)coits•tr•t(cied is accordaace with
7.Is this a repair to an existing well: ❑Yes or GNo 15A NCAC 02C.0100 a•151t NCAC 02C.0200 It ell Construction Slmularrls and that a copy
1 this is a repair,fill out known well construction in/brntation and avplain the nature ol'the of tlds record has been provided to the well owner.
repair under 1121 rarrarks section or on the back of this fr•nt.
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'Sce Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
24.SUBiIMITTAL INSTRUCTIONS
9.'I'otal well depth below land surface: 225 (ft.)
For nurhiple wells list all depths i(d/Qereni(avangde-3@200'mud 2 n 100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 40 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+^ Information Il.rocessing Unit,1617 MSC,Raleigh,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
12.Well construction method:
(i.e.auger,rotary,cable,direct push,etc.) 24c.For Water Supply and Open-Lotip Geothermal Return Wells•Copy to the
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(gpm) 10 Method of test:AIR Permit Program,1611 MSC,Raleigh,N,C 27699-161 1
c
13b.Disinfection type: HTH Amount
Form G W-I North Carolina Department of Environmental Quality-Division of Wutcr Resources I Revised 6-6-20I S