GW1-2023-00508_Well Construction - GW1_20230104

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WELL CONSTRUCTION RECORD (GW 1) For Internal Use Only: � 1
I.Well Contractor Information:
CHAD HARTNESS
'14.WATER ZONES
Well Contmet.r Nam. FROM TO DESCRIPTION
2901 A 289 ft. 2s0 ft. f i
ft. ft. i
NC Well Contractor Certificrdion Number
AIR DRILLING I N C 15.OUTER CASING for multi-cNediwelis OR LINER if a licable
FROM TO DIAMETER; TIIICKNESS MATERIAL
Company Name 0 ft. 57 ft- 6 ' in- 1PVC
359451 16.INNER CASING OR TUBING cothermal closed-loop)
2.Well Construction Permit#: FRO\f TO DIAMETER TIIICKNESS MATERIAL
List all applicable Well consn•uc'tlon permits(i.e.U1C,County,Sttete, Vminnce,etct) fL ft, in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN •
FROM 'I'O DIAMETER SLOT SI%E 'I•IIICKNESS MATERIAL
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) L9Residcntial Water Supply(single)
ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
18.GROUT
❑lrri�ation ❑Wet ls> i00,000 GPD FRWI TO M,CTERL\L EMPLACEPIENT METIIODSAMOUNT
Non-Water Supply Well: 0 ft. 20 rt. GROUT POURED
❑Monitoring ❑Recovery ft. ft.
Injection Well:
❑A uifer Recharge ft. ft.
9 g ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinit Barrier 19.SAND/GRAVEL PACK if o licable
y FROM TO MATERIAL EMI'LACEMENTMETIIOD
❑Aquifer Test ❑SlormwaterDrainage
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Gcothcrnmal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,graln size,etc.)
0 rt. 47 ft• DIRT
4,Date Well(s)Completed: 6-1-2022 Well ID# 47 fL 305 ft• ROCK
Sa.Well Location: ft. ft.
PORTER & CRESS rt. ft.
Facility/Owner Name Facility lDS(ifapplicable)
4270 NEEDMORE RD,WOOD LEAF,N.C. 27054 'y Lv )
Physical Address,City,and Zip ft. 7 O
ROWAN 708099 21:REMARKS -
count), Parcel Identification No.(PIN) I c i- YS pr^,r, ai '
1 t :r•
J Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one let/long is sufficient) ertil- tion:
35e 48.591 N 80- 38.485 W
7 •6/1/2022
6.IS(are)the well(s):I MPermanent or ❑Temporary Signature or Certified Well Contractor - Date
By.rignittg tliis form•1 hereb},cei-16fj,tlal the wel/(c)teas(mere)cotrrtrticied in accordance with
7.Is this a repair to in existing well: ❑Yes or (nNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
lfdtis is a repair fill out known❑yell construction information and explain the nature of the q/'diis record has heen provided to the well owner.
repair under 021 reuurb section or an 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 305 (tt)
For multiple wells list all depths/fdierent(erample-3 a200'and 2 r@i 100q Submit this GW-1 within 30 days of well completion per the following:
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10.Static water level below top of casing: 40 (ft) 24a. For All Wells: Original fora) to Division of Water Resources (DWR),
1f water level is above rasing,use + Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in,) 24b. For Injection Wells:Copy to IDWR, Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:
(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 Wells producing over 100 000 GPD Copy to DWR,CCPCUA
13a.Yield(gpnt) 1 Method of test AIR Permit Program,1611 MSC,Raleigh,NC 27699-16I 1
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13b.Disinfection type: HTH Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources i Revised 6-6-2018
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