GW1-2023-00509_Well Construction - GW1_20230104

WELL CONSTRUCTION RECORD (GW-1) Por internal Use Only:
I.Well Contractor Information:
CHAD HARTNESS 14.WATER ZONES i
Well Contractor Name FROM Pro DESCRIPTION
2901 A 249 ft- 250
ft. ft. f
NC Well Contractor Certification Number
AIR DRILLING I N C FR 15.OUTER CASING for multi-cased wells OR LiNER iC a licablc)
OM TO DIAMETER TIIICKNESS MATERIAL
ft. 48 ft. 6 in. /+
Company Name p PV li
369209 16.iNNER'CASINGORTURiNC cothcrmalclosed-too
2.Well Construction Permit#: FROM TO UTAA7 ETER TIIICKNESS MATERIAL
List all applicable well constr uclion permits(i.e.U/C,County,Slate,14rrionce,etc.) ft. ft, in.
3.Well Use(check well use): ft. ft. ire.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS I MATER1A 1.
❑Agricultural ❑Municipal/Public ft. ft ill.
❑Geolhcnml(Pleating/Cooling Supply) Li Residential Water Supply(single) ft.
❑industrial/Connncreial ❑Residential Water Supply(shared)
IS:GROUT
❑irrigation ❑Wel Is> 100,000 GPD FROdI I TO ,%IATERIkL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 f' 20 ft• GROUT POURED
❑Monitoring ❑Recovery
Injection Well:
ft. rt.
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinit Barrier 19.SAND/GRAVEL PACK if a ncablc
Y FROM TO MATERL�L EMI'LACEpIF,NT MF:T110D
❑Aquifer Test ❑Storinwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional streets if necessary)
❑Geothermal(licating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiVrock tyre, rain size,etc.
p fL 38 t' DIRT '
4.Date Well(s)Completed: 05-20-2022 Well ID# 38 f' 265 ft ROCK
5a.Well Location:
MSL HOMES rt. ft. n7- , ,
Facility/Owner Name Facility iD#(ifapplicable) ft. ft. "^^7 a q -..'Li;'
360 RIDGEWOOD DR MT ULLA, N.C. 28125 JAN Q 4 2023
Physical Address,City,and Zip ft. ft.
ROWAN 566080 21.REMARKS
County Parcel identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one let/long is sufficient) u
a
ion: - - -
35° 39.485 N 80° 43.545 W ., ,
�•�.- . 5/20/2022
6.Is(are)the wcll(s): IJPermanent or ❑Temporary Signature of Certified Well Contractor Date
Uy•signing thisform,thereby certifj'that the well(s)was(were)constructed ire accordance with
7.Is this a repair to an existing well: ❑Yes or CJNo /SA NCAC 02C.0100 at-15A NCAC 02C.0200 lie/1 Construction Standards and that a copy
tf 1his is a repair•fill out known well construction ir(/a•mation and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section ar on the back of this farm '
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-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages(friccessary.
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 265 ft.
Fori ndtiple wells list all depths t/'dif)crenl(esample-3 a.200'and 2 rr 100') ( ) Submit this GW-I within 30 days of well completion per the following:
10.Static water level below top of casing: 40 ft 24a. For All Wells: Original form to Division of Water Resources (DWR),
6/'water level is above casing,use"+" ( ) Information Processing Unit, 1617 MSC,Raleigh,NC 27699-
11.Borehole diameter: (in,) Injection Co C)1617
6 24b.For Injection Wells: Copy to DWR, Underground Inje trol(IU
Program, 1636 MSC,Raleigh,NC 27699-1636
Well construction method:
(i.e.
24c.For Water Supply and Open-hoop Geothermal Return Wells:Copy to the
.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPI:Copy to DWR,CCPCUA
13a.Yield(gpm) 6 Method of test:AIR Permit Program, 1611 MSC,Ralcigh;NC 27699-1611
136.Disinfection type: HTH Amount:
I
Form G W-I —_ North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-201 S
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