GW1-2023-00490_Well Construction - GW1_20230104

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WELL CONSTRUCTION RECORD (GW 1) For Internal Use Only:
1.Well Contractor Information:
CHAD HARTNESS 14;WATERZGNES " ,.
Well Contractor Nam. FROM TO DESCRU-3ION
2901 A 288 ft• 289 ft-
ft.
NC Well Contractor Certification Number
A I R DRILLING I N C 15.OUTER CASING for multi=cased-wells OR LINER if a licable)
FROM TU DIAMETER THICKNESS MATERIAL
Company Name 0 rt• 97 ft• 6 1n. PVC
354985 16.INNER CASING OR TUBING. eothermat closed-loo ,
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable it-ell construction permits(i.e.UIC,County,State,Variance,(tc.) ft• ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN'
❑A 1CLLltllral FROM TO DIAMETER SLOT SI%E 1'}IICKNESS NATP;RIAI,
❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) [!]Residential Water Supply(single)
ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) E�
'18.GROUT'
❑Irrt ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD S AMOUNT
Non-water.supPly Well: 0 rt 20 rt GROUT POURED
❑Monitoring ❑Recovery ft. ft.
Injection Well:
❑A uifer Recharge ft R•
9 g ❑Groundwater Remediation
❑A uifer Storage and Recovery 19,SAND/GRAVEL PACK if a licable
9 g ry ❑Salinity Barrier FRO\I TO MATERIAL EMPLACEMENT METHOD
❑AGuiferTest ❑StormwaterDrainage ft. tt.
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soilfrock type,gmin size cic.
0 rc. 87 ft- DIRT
4.Date Well(s)Completed:4-22-2022 Well ID# 87 f`• 305 ft- ROCK
5a.Well Location: ft. ft.
BARNHARDT CONST n. ft. 11 ,
Facility/Owner Name Facility iD#(ifapplicable) ft. ft,
110 LOCHSHIRE LAN EXOOD LEAF,N.C. 27054 ft. ft. t
Physical Address,City,and Zip
ROWAN 8174052 21:REMARKS
County Parcel Identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:'
(ifwell field,one latllong is sufficient) �_
350 45.376 N 80- 34.339 2'C�tifica' n:
6.Is(are)the well(s): [']Permanent or ❑Temporary Signature of Certified Well Contractor Dale
iiysigning this farm,/hereby cerr(fv that the Irell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or [!]No 15A NC4C 02C.0100 or 15A NCAC 02C.0200 lVell Construction Standards and that a copy
lfthis is a repair,fill otut k1101vn bell construction'inforniation and explain the nature ofthe of this record has heen provided to the ive//,owner.
repair under#21 renmrla 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'Sce Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 305
For miultiple wells list all depths ifdperent(example-3 r@200'and 2 a@100) (f t) Submit this GW-I within 30 days of well completion per the following:
10.Static water level below top of casing: 30 (ft) 24a. For All Wells: Original form I to Division of Water Resources (DWR),
If ivater 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:
(i.e.auger,rotary,cable,direct push,etc.) 24e.For Water Supply and Open-L lop Geothermal Return Wells:Copy to the
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producine over 100 000 GPD Copy to DWR,CCPCUA
13a.Yield(gpm) 5 Method of test:AIR Permit Program,161 I MSC,Raleiglm,NC 27699-1 6 1 1
13b.Disinfection type: HTH Amount
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Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 6-6-2018
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