GW1-2023-00427_Well Construction - GW1_20230103

i
WELL CONSTRUCTION RECORD (GW 1) For Internal Use Only:
I.Well Contractor Information:
CHAD HARTNESS
14.WATER ZONES
Well Contractor Name r•Roat TO DEscRir,non
2901 A 229 ft- 230
ft-
ft. ft.
NC Well Contractor Certification Number
A I R DRILLING I N C is.OUTER CASING(for m°'ti-eased.`ve"S OR LINER(if a licable
FRO\t TO DIAMETERI TIIICKNESS MATERIAL
Company Name
ft. ft. in.
313491 16.INNER CASING OR TUBING eothermat closed-loon)
2.Well Construction Permit#: FROM TO DIAMETER TIIICKNESS MATERIAL
List all applicable urn/construction perinits(i.e.UIC,County.State,Variance,vie.) 0 ft, 85 ft. 6 in, GALV
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.'SCREEN
FROM TO DIANWTER St. TSIZE THICKNESS NIATERIAL
❑Agricultural OMunicipal/Public ft. rt. in.
❑Geothermal(Heating/Cooling Supply) ClRcsidential Water Supply(single)
ft-
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑hTi gation ❑Wells> 100,000 GPD FROM TO I MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 20 ft- GROUT POURED
❑Monitoring ❑Recovery ft. ft.
Injection Well:
rt.
❑Aquifcl•Recharge ❑G ft.roundwater Remediation '
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETIIOD
❑Aquifer"lest ❑StorniwatcrDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control rt. rt.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(1-Icating/Cooling Return) ❑Other(explain under#21 Remarks) FROd1 TO DESCRIPTION(color•hardness.soil/rock type.grain size,cic.
0 "' 75 rt DIRT
4.Date Well(s)Completed: 06-02-2022 Well iD# 75 ft• 245 rt ROCK
Sa.Well Location:
QUINN WIERCK ft. ft. T
Facility/Owner Name Facility lD#(irapplicable) ft. ft. J�} 11 HIV N n �
133 NATURE'S WAY, HAMPRONVILLE,N.C. 27020
Physical Address,City,and Zip ft. ft. 1"ri:;Fii;T:771 ;'f;4.yW;1„�� Unil
IREDELL 4863512932 21.REMARKS
County Parcel Identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IaUlong is sufficient)
V. ertifi ion:
360 11.928 N 80- 48.302 Ni 6/2/2022
6.Is(are)the well(s): ❑Permanent or ❑Temporary Signature ofCertifted Well Contractor \` Date
BP signing this form,/hereby certi/i•that the tvell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or nNo /51f NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
ifthis is a repair.fill out knotvn well construction hifornration and explain the nature o'the of this record has heen provided to the well owner.
repair antler#21 remarks section at-on the back of this forin,
23.Site diagram or additional well details:
3.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'Scc Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 245 ft.)Fornhuhiple it-ells list all depths ifdi(fcrent(craurple-3 a200'and 1 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),
/'stater level is above rasing,use"+^ ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6 24b.For Injection Wells:Copy to DWR, Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
1..Well construction method; 24c.For Water Supply and O cn-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 WATCH SUPPLY WELLS ONLY: 24d,For Water Wells producing over I"0"GPD: Copy to DWR,CCPCUA
13a.Yield(gpni) Method of test: mtt
AIR Pat Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources ,
Revised 6-6-2
U18