GW1-2023-00407_Well Construction - GW1_20230103

i
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
CHAD HARTNESS
14:WATER.ZONE$
Well Contractor Name FROM TO DESCRIPTION
2901 A 249 ft- 250 ft, I '
INC Well Contractor Certification Number ft. rt.
�15+•OUTER::CASING,for multi-eased:-wells OR LINER if a licable
A I R DRILLING I N C
FROM TU DIAMETER t THICKNESS MATERIAL
p fc. gp 6 In.
Company Name rr. PVC
323739 16'.INNER,,CASING OR TUBING: eotliernial closed-loo . ' .-
2.Well Construction Permit#: FROM TO I DIAMETER I T1nCKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use):
Water Supply Well: 17.SCREEN
FROM TO DIAMETER S1.OTSV'.E 'rF1ICKNFSS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) In Residential Water Supply(single) ft. ft. in.
❑Industrial/Commcrcial ❑Residential Water Supply(shared) 18„GROUT
01nigation ❑Wells>100,000.GPD FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0 rt. 20 tt. GROUT POURED
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft, tt.
❑Aquifer Recharge ❑Groundwater Remediation
19:.SAND/GRAVEL PACK fifarmlicahle.1
❑Aquifer Storage and Recovery ❑Salinity Barrier FR0.N1 TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20::DRILLING LOG attach additional sheRs'if.necessar
❑Geothermal(Hcating/Cooling Return) ❑Other(explain under#21 Remarks) p FROM TO DESCRIPTION color,hardness,soNrock type,grahe size,etc.
rt. 80 rt. DIRT
4.Date Well(s)Completed: 4-21-2022 Well ID# 80 ft• 265 ft• ROCK
5a.Well Location: ft, ft.
SPIVEY CONSTRUCTION
Facility/Owner Name Facility iD#(ifapplicable) -
115 TRAVIS POINT, MOORESVILLE,N.C. 28117 J A 1
Physical Address,City,and Zipr.i 'I Uri!
-2L.REMARKS IREDELL 4645064449 - -.t;..' ::•.�:i::.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one]at/long is sufficient) 2 Certii- tion
35° 32.204 N 80° 52.531 , 4/21/2022
6.Is(are)the well(s): [!]Permanent or ❑Temporary Signature of Certified Well Contractor 'l;. Date
By signing thisfornr,1 hereby cent fi,drat the tvell(s)ivas(were)constructed in accordarce with
7.Is this a repair to an existing well: ❑Yes or InNo 15A NCAC 01C.0100 or 15A NCAC 01C'.0100 Well Construction Standards and that a copy
If this is a repair,fill out known well construction in formation and explain the nature ofthe of this record has been provided to the iveU owner.
repair tender#21 remarks 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 1 GW-1 is needed. Indicate TOTAL NU.MBER of wells (add'Sce Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: i
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 265 fL
For nialtiple wells list all depths ifdiffereni(example-3 a 100'and 2@100) ( ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 20 ft, 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifivater level is above casing,use"+" ( ) Information Processing 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: 24c.For Water Supply and Open-I oop 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(gpm) Method of test:AI R Permit
20 Program,1611 MSC,Raleigh;NC 27699-1 6 1 1
13b.Disinfection type: HTH Amount-
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised'6-6-2018