GW1-2023-00500_Well Construction - GW1_20230104

i
WELL CONS`I`RUCTION RECORD (GW 1) Tor Internal Use Only: i -- —
I.Well Contractor Information:
CHAD HARTNESS
14 wA rrR ravhs ------1
Well CuniractorNamc FR.OJI__I'0 DIiSCltli'TION -----
2901 A
NC 1Vc11 Conhnelor Ccr(ificulion Nunil,cr f t.AIR DRILLING I N C I5.OUTER CASING(1'm multi-cased;wells)OR LINER(if a) lic;(hlc)
FRO\f _ 1'U DI,\�iR.TG.R THICKNESS a1ATEIMI.
Company Name 0 ft. 52 PVC --- -
379128 16,1NNE12 CASING oR TUBING 'eathernral closed-lo -
2.Well Consh'uction I'crmit fl: ---�- -- —FROM -ro - UI:\YII?'1'4:R 'i'IIICKNESS ---'
l.isr aft applicable well c•ons•hva'tian permlls(i.e.(/lt.',CouulF.Sral<•, I'rrr•inne•r•,etc•.) ..-._._-=-------...__...._
fl, fl. in.
3.Well Use(checl<,Vcll use);
Water Suplily Well: 17,SCREEN — ----
❑Agricultural FROM I'U — DI\ 11•:I'IS 11 SLOT SIZE 'I111 I(NE S kL\TERIAI.-
DMunicipal/l ublic ft. - --
1-1Gcolhern,al(Beating/Cooling Supply) Mllesidentiai Water Supply(single)
ft.
DIndustrial/Con,n,ercial ❑Residential Water Supply(shared)
18,GROUT
❑h'I'- ahl 0Wells> 100,000GPD FRO.)I TO 11ATERIAL. [�1PI,,\CE\IF.NTi14E'I'IfOD,@,\,b(OUNT
Noll-Wafer supply wee: 0 rf 20 r' GROUT POURED
❑Monitoring ❑Recovery -
Injection Well: --_:Aquifer Recharge (:]Groundwater Itcmediation I'' ft• - — __-.___��
I_IAyuifcr Storage and Recovery CIS rlinit I3arricr 19.SAND/GRAVEL PAC]( Ifs ILllea0lc
Y FRUMi '1'O \7,1'1'I1.Rh1L IiNI I'LACE..pi(iNTA I Ii'I'I l q p -I
-lAquilet-Test ❑Storn,waterDrainage ft. 1t,
1F.xperin,ental'fechnologY ❑Subsidence Control fL --- fl, - __---_---"-
f_IGcothcn'nal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
11Geothernull(Pleating/Cooling Return) ❑Othc:•(explain under It?I Remarl(s) FRUI to - DESCRIPTION(color,L..rnncss,sulu;oeluvL�rnln sire,r,_)--
12-7-2022 0 — ft- 42 f'_ DIRT _
4.Date Well(s)Complerc(1: Well IDII 42 1" 305 f'' ROCK ----- _....._--
Sa.Well Location: 1'l. - ff--- -------- ' - ---
JOSH SNYDER
facility/Owner Name fI, It. "^F v
acility IDII(ir;q,plici)61c)
1285 WETMORE RD,WOODLEAF,N.C. 27054 ft, It•
PhysienI Address,City,and Zip rL ft,
ROWAN 809047
21.REMARKS
('ounly Parcel Identi6einion No•(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if u•cll r46ne ku/Ming is sunlcient)
39 N 80° 34.363 ( b
12/7/2022
6.Is(are)the well(s): C111crmancnt or 01'emporary Signature ol'Ceriifred Well Contractor Dime -
Bj•signing this•Jbrm.l herchl,c•er•tj&that the wel!(s)❑as(were)cons'iracterl in arrorrluueu irilh
7,Is Illis 11 repair to an existing well: ❑Yes or 1JNo 15.4 NC'AC a7.C.0100 or 15A NCAC 02C.0200 Well Coasu'actialr S'laralarrlx and that a(apf
!/•this is a repair.•/ill oar known wall consrrac•tion in/brnration and explain the nature q(Nre of'diis record hashem provided it)the it-H owner.
repair under/121 reaaa•ke•sec-lion at-on tine hack of 1his•/itrnl.
23.Site(diagram or additional well details:
S.For Geoprobe/DPT or Closed-I,00p Geolhernull Wells having the same You may Ilse the back of this page to provide additional we11 construction inlb
construction,only I GW-1 is ncadc(I. Indicate TOTAL NUMBER of wells (add'Sce Over'in Remarks Box).You stay also attach additional pages if necessary.
drilled:
- - -- 24.SUBNlITTAL INSTRUCTIONS
9.Total well depth below land surface: 305
har rnehiple u•ellr list all depths iJ'di(Jcrent(example-3@),200'mrd 2 100') Submit this GW-1 within 30(lays ol'nvcll con,plcidon th per e fallowing:
10.static water level below top of casing: 60 (ft.) 24a. For All Wells: Original fora, to Division of Water Resources
{i'walm'level is•ahore cas•iag,livu"•r•' Information processing IJnil, 1617 MSC,Raleigh,NC 27699-1617
11.Borehole ddamcter: 6 241),For Injection Wells: Copy to DWR, Underground Injection Control (I(J(`)
program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:
(i.e.auger,iolary,cable,dheet push,etc.) - 24c.For Water SupplZmul Open-Lo'op Genthermal Return Wells:Copy to the
county environmental health cleportmerit of the county Where installed
FOR WATER SUPPLI'WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD; Copy to DWR,CCPC'tJA
13a.Yield l)Ill rmit 1 rograli,, 161 1 MSC,Raleigh,NC 27699-161 1
(11 ) — Method of test:
i
tab.Disinfection type: HTH Amount:
Form Ci\V-I North Carolina Dcparuncul of HnvironmcnhitQuuhty-Division of Water Resources i
i Revised 6-6-:1011
I i
� 1
+ I
i