GW1-2023-00496_Well Construction - GW1_20230104

i
WELL CONSTRUCTION RECORD (GW 1) For Internal Use Only:
I.VT ell Contractor information:
CHAD HARTNESS !
MFRONITO
t
Well Comractor Name nESCItIP'I'ION
2901A NC Well Contractor Certification Number
AIR DRILLING INC for m°'I-eased,vell5 ORLf NER(if a licableDI.\METER THICKNESS MATERIAL
Company Name 0 ft- 86 ft. 6 in. PVC
367375 16:INNER CASING OR TUBING('eotherntat closed-loop)
2.Well Construction Permit#: FROM I TO DIAMETER THICKNESS MATERIAL
List rill applicable hell construction permits(i.e.UiC,County,State,Pariaece,etc•,) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
❑A+rICDI(ural FRO\I TO DIAMETER S1.0T SI/,M; THICKNESS MA'1'ERIAI,
b ❑Municipal/Public ft. ft. In:
❑Geothermal(Heating/Cooling Supply) C1Residential Water Supply(single)
Ct. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
18.GROUT
❑irri gation ❑Wells> 'An Ann GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 rt• 20 ft- GROUT POURED
❑Monitoring ❑Recovery ft. ft.
Injection Well:
❑A uifer Recharge « ft.
Remediation❑Aquifer Storage and Recovery ❑Salinit 19.'SAND/GRAVEL PACK if applicable)
y Barrier RoLAL EMPLACEMENTMET METHOD
❑Aquifer Test ❑StonnwaterDrainagc F at To«• ft. \1ATER
❑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) FRO\I TO DESCRIPTION(color,hardness,softock type,grain size,etc.)
p rt. 76 ft• DIRT
4.Date Well(s)Completed: 10-10-2022 well ID# 76 ft' 345 ft- ROCK,
Sa.Well Location: «. ft.
TREXLER CONSTRUCTION ft.
Facility/Owner Name Facility iD##(if applicable) ft. ft.
1020 DEVONPARK , SALISBURY,N.C. 28147 ft. rt. QN A G 2023
Physical Address,City,and Zip ft. ft.
ROWAN 458DO18 21.RENIARKS 77
County Parcel identification No.(PIN) '
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient)
350 40.161 N 80- 33.013
W P ° � --�- 0/10/2022
6.Is(are)the well(s): ❑Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this•form,1 hereby certdfi,that the Nell(.)ivas(were)consa•mcled in accordance mvith
7.Is this a repair to an existing well: ❑Yes or PJNo 15A NCAC 02C.0100'ar 15A NCAC 02C.0200 Well Construction Standards and that a copy
//•this is a repair,.fill out knouvt well consm•ticlion inloratation and explain the nature ofthe gfthis record has been provided to the we!l atrner.
repair under##21 t•entarks section ar oil the hack of thit•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 info
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'Sec Over'in Remarks Box).You nmay also attach additional pages if necessary.
drilled:
24.SUBMITTAL INSTRUCTIONS',
9.Total well depth belowland surface: 345 -(ft.)
For nudtiple wells list all depths ifdierew(erantple-3 a 200'and 2 a,100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing• 40 I(ft) 24a. For All Wells: Original foram to Division of Water Resources (DWR),
1f rater level is above casing,use"+^ information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6 lira.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12•Well construction met push.
(i.e.auger,rotary,cable,direct push,etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water VVclls producing ove!100,000 GPD• Copy to DWR,CCPCUA
13a.Yield(gpm) 10 Method of test:.AIR Permit Program,i 61 I MSC,Raleigh,N I C 27699-1611
,
13b.Disinfection type: HTH Amount
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 6-6-2018