GW1-2023-00396_Well Construction - GW1_20230103

WELL CONSTRUCTION RECORD (GW-1) For internal Use Only:
I.Well Contractor Information:
CHAD HARTNESS 14.WATER ZONES
Well Contractor Name FROM •1'0 DESCRIPTION
2901 A 209 ft- 210 ft. l
ft. ft.
NC Well Contractor Certification Number 15.OUTER'CASiNG for multi-eased.wells OR LINER if a licable)
AIR DRILLING I N C FROM TO DIAMETER THICKNESS MATERIAL
Company None 0 57 ft. 0 1 in. PVC
303432 16.INNER CASING OR TUBING edthermal closed-loop)
2,Well Construction Permit#' FROM TO DIAMETERM THICKNESS ATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Paricace,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROSNI CREENf o DIAMETER sLoT SIZF THICKNFSS MATERIAL
❑Agricultural ❑MunicipaVPublic ft. rt. in.
❑Geothermal(Pleating/Cooling Supply) ClResidential Water Supply(single) ft. ft. in.
❑industrial/Colnlmelcial ❑Residential Water Supply(shared) I&GROUT
❑irrigation ❑Wells> 100,000 GPD FROdI I TO MATERIAL EMPLACEa1ENTMETHOD&AMOUNT
Non-Water Supply Well: 0 f' 20 f' GROUT POURED
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
'19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METIIOD
❑AquifcrTest ❑StormwatcrDrainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Gcothernial(Heating/Cooling Return) ❑Other(explain under 421 Remarks) FROM TO DESCRIPTION color,hardness,sotUrock type.grain size,etc.
0 rt. 47 rL DIRT
4.Date Well(s)Completed: 05-27-2022 well ID# 47 r' 225 f'• ROCK
Sa.Well Location:
ft. ft.
BLUEFIELD BUILDERS
"s
Facility/Owner Name Facility iD#(ifapplicable) ft. ft.
131 BUTTERCUP DR,MOOREIZILLE,N.C. 28117 ft. ft.
Physical Address,City,and Zip ft. ft.
IREDELL 4614738928 1 21.REMARKS r'•s'!i` r1,:_ ✓
County Parcel Identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one lat/long is sufficient) 2 . erlifi lion:
350 30.144 N 800 57.233 �, �; �- .".
5/27/2022
6.Is(arc)the wcli(s): InPermanent or ❑Temporary Signature of Certified Well Contractor Date
Bysigning this form,I hereby certify that the well(s)ryas(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and arplain the nature of the of this record has been provided to the+Pell owner.
repair under 1121 remarks section or on the back of this form.
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction into
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.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 225 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For ondtiple wells list all depths if thereat(example-3 a 200'and 2 cDi 100')
20 24a. For All Wells: Original form to Division of Water Resources (DWR),
fwater level is above casing,use 10.Static water level below lop of casing: information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
if "+"
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
Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 75 Method of test:AIR
13b.Disinfection type: HTH Amount: f
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-201 S
II` '
i