GW1-2023-00497_Well Construction - GW1_20230104

WELL CONSTRUCTION RECORD GW-1
For Internal Use Only:
1.1Vd1 Contractor Information: I —
CHAD HARTNESS J
14.WATER ZONES Well CimlraClol'Name GRO\i_ ,I'0 _ I)ESCRIP'['[ON
2901A 409_ fl: 410 ft. ` ----
NC:Well Conti-actor Cerlificmion Number ft.
AIR DRILLING I N C I5,OUTER CASING(for i»uttf MET wells)I LINER if a) Iirtble)
_fRUal —T'p)_ — DL\111?'1'R.Ri _TII IC'K N GSS \1:tTf121.\I.
Company Hume 0 ft. 73 ft. PVC
379279 16.INNER C,ISING OR TUBING(geothermal closed-loo ) -
2,Well Construction permit ll: ItROaI Tp Ula\7 F:f[tR' _TIIICKNCSS \Ia'fliRL\I.
List all applicable nrll construction pernrit.r(i.e.tIIC.C.'ountr.Slnle, hiu iauce,ere,) ft. ---fl. in. ---_--
3.Well Use(checl(well use): ---ft, ft. in.
Water Supply Well: I7a_oaCiRft,E EN_rD—it. EITEiva. —Slorst TERIAl.❑A ricuhural EIMunicipal/,ublic rs c
-
-- - -
NESS
DGcothernlal(Heating/Cooling Supply) I•_JResidential Water Supply(single) ---- - ----_-_.--
ft.
IJinduslrial/Commercial ft.
WaterSupply(shared) 7
s.GROUT' --
❑Irrig tion M We]Is> 100,000GPD moat TO 51ATEMIAL ENn'LACP.a1ENTNIE.ruon.z.ANIOUNT
Non-Water Supply Well: 0 f'• 20 f' GROUT POURED
❑NIonitoring ❑Recovery ft, ft, -- --- "
Injection Well:
❑A a uii'cr Bechar ft.
q g ❑Groundwater Remediation
❑Aquiler Storage and Recovcl 19.SAND/GRAJPACKif applicable)y DSalinityBarrier MATLtlrLL]AquilbrTest CJStormwaterDrainage ft•❑F.eperiniental'1'cchiiology ❑Subsidence Control ft, — -- ----- -
I ICioolhcrrnal(Closed Loop) ElTracer 20.DRILLING LOG attach additional sheets If necessary) �1
I :(icoiltea•nutl(I lotting/Cowling Return) 170thcr cs�luin tauter U2 ) PBoat— '1.O __^_ Otscitu''fuiN tc;tr,n t,ard„c,s,sr,tu,orlr iv�a caia st.c,etc.,
( I I Rcrnarks 0 f' 63 I'L _---_..--_-1-_E._._.__.__..__.._.,
12-2-2022 _ — --=- —----- ----
4.Date NVcll(s)Completed: Well ID/I 63
'•'' 425 I'• ROCK
Sa.Well Location: f—i - it---'-- -- ----�
IH POPE FARM ft• ft. -� m a
Facility/OwnerNamc FacililyTDti(ifctpplicuble) ft, ft. ----
3320 WEST INNES ST,SALISBURY,N.C. 28144 ----
Physical Adcb'ess,City,and/_i) ft. fL _ I
n.t
ROWAN I i.,
320294 21.RENiARICS- e
County parcel Identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/lung is sufficient) 22.Certifreafioll:
350 42.536 N 80- 29.272
12/2/2022 `
6,Is(arc)the well(s): [!]Permanent or ❑Temporary Signature ofCeniftccl Well Contractor Dote
By signing this form 1 hereby m-li/i-that the a ell(s9 n as•(were)Constructed in accordance 114111
7.Is this a repair to an existing well: FJVes of CINo MI NC;:IC 02C.0100 or 15A rVC''4C.02C.0200 11'W1 Consit"feliorl Slemetar lr and that a cope
11"his is el repair,,lill out known well Construction hilbrination and explain the nature o/'the (j'chi.r record has hum provided to the well owner.
rrpuir under tl.?1 reolarks section or on the back afthi.r./orrn.
23.Site diagram or additional well details:
8.ForGeoproheffl!"T or Closed-Loop Geothermal Wells having the same )'on may use the back of this page la provide additional well constuction,11110
ron.;lruclion,only I G\V-1 is needed. I11dicate'1.OTAL NUMBER()['wells Odd'Sce Over'in Remarks Box).YOU May 81SO attach additional pages if ncoeSSary.
drilled:_.-_.________._____
z4.sutln'u'i"I'AL INSTRUCTIONS.
9.Total well depth below land surface: 425
oft.)
For nnrhiple"'ells licl all depth-7 i•'/'c4lPrent(avangrle-3@200'unrl2 a,100') Submit this GW-1 within 30 days of well completion per(he following:
10,Static water level below top of casing: 30 oft,) 24a. For All Wells: Original form to Division of Water Resources ('DWR),
Il'a•aler level is above casing,use"+" Information processing Unit, 1617 MSC,Raleigh,NC 27699-1617
i
I I,Borehole diameter: 6 (in,) 24b.For Injection Wells: Copy to DWR, Undergroun(t Injection Control(I(1(.')
program, 1636 MSC,Raleigh,NC 27699-1636
1.e alien construction method: 24c.For Water Su )lv and O en-1,,,6 Geothermal Return Wells:Copy to the
(i.e.;roger,rotary,cable,direct push,cte.) coturty'eiroiionrnental heap I I cpurhrtunl.ef the county where installed
h0)2 Wr\'f[sR Si1PPLl'WELLS ONLY: 24(h rat•Water Wells producing over 100 1011i
GPI)' Copy to DWR,CCPC•UA
13a.Yield(gpm) 3 Method of test: AIR Permit Program, 1611 MSC,Raleigh,NC'27699-161 I
I
13b,Disinfection type: HTH ArnounL .
' I
Pura G W-I North Carolina Dcparlmcnl of Environmental Quality-Division of Walcr Resources + Revised 6-6-201 S
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