GW1-2023-00420_Well Construction - GW1_20230103

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WELL CONSTRUCTION RECORD(GIN 1) For Internal Use Only:
1.Well Contractor Information:
CHAD HARTNESS
14:-WATER'ZONES
Well Contmctor.Neme FROM=DESCA111,,rIM0RN2901A 409 NC Well Contractor Certification NumberAIR DRILLING INC FROEM ERCASING.for.multicase!LVK is OR•LINER ifa livable
FROM TO DLIMETER THICKNESS MATERIAL
Company Name 0 ft. 5-6ft• 6 1D GALV
2.Well Construction Permit#.
309873 16..lNNER CASING'OR TUBING 'eothei mat closed-loo
FROM TO DIAMETER
List all applicdble hell construction permits(i.e.U/C,County..Srate,Variance;etc.) ft. ft. i THICKNESS MATERIAL
n.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 47.SCREEN
❑A ICLLltural FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Municipal/Public fL ft. in.
❑Geothermal(Heating/Cooling Supply) C1Residential Water Supply(single)
ft.
❑Industrial/Commercial ❑Residential Water Supply(shared)
h7i anon 18:GROUT,
❑ '• �;
❑Wells>lOQ 000 GPD FROM TO _ 11fATER1AL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0 ft' 20 ft. GROUT' POURED
❑Monitoring ❑Recovery ft ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation ft. ft.
❑Aquifer Storage and Recovery l7Salini Barrier .19.SAND/GRAVEL,PACK(ifs livable -_
ty FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
4
❑Geothermal(Closed Loop) ❑Tracer 30.DRILLINGrLOG`atfsch�additibual shects.if necessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21_Remarks) FROM TO DESCRIPTION color,hardness,softock e,grain sae,etc.
- 0 ft' 46 fa DIRT
4.Date Well(s)Completed; 2-1-2022 Well ID# 46 ft 425 ft- ROCK
5a.Well Location: ft. ft.
JOHN BOUNDS fa ft
Facility/Owner Name Facility lD9(ifapplicable) ft % I LJ
702 STONEMARKER, MOORESVILLE,N.C. 28117 ft ft `
Physical Address,City,and Zip ft ft
IREDELL 4624195098 21.REMAPM _ -
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 2. rtific on:
35e 31.556 N 800 56.375 �Y� � -
w -�� 2/1/2022
6.Is(are)the well(s): C1Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or InNo 1SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
/f this is a repair fill out known well construction information and e'rplain the nature of the of this record has been provided to the well owner.
repair under 921 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 NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 425 (ft)
Formul!lple wells list all depths ifdierent(example-3t200•and 1Q100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 25 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwater level is above casing,use'•+• Information Processing Unit,1617 MSC,Raleigh,NC'27699-1617
II.Borehole diameter: 6 (in,) 24b.For Infection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
.Well construction method:
(i.e.auger,rotary,cable,direct push,etc.) 24c.For Water Supp1v and Open-L000 Geothermal Return Wells:Copy to the
county environmental t department o e county where installed
FOR WATER SUPPLY WELLS ONLY: t
24d.For Water Wells producing over!-100 000 GPD• Copy to DWR,CCPCUA
13a.Yield(gpm) 5 Method of test: AIR Permit Program,1611 MSC,Raleigh,NC 27699-1 11 I
i
13b.Disinfection type: HTH Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources If Revised 6-6-20/8