GW1-2023-00540_Well Construction - GW1_20230104

WELL,CONSTRUCTION RECORI) (;JV-I
For Internal Use Only: �.
I.Well Contractor int'ormation: ;
CHAD HARTNESS
14,WATER ZONES i
Well Contractor Namc IrltOnl '1'0 DP:SCRIP'1'ION
2901 A 489 —ft- 490 n• — '
NC Well Contractor Certification Number ft. ft. I1
AIR DRILLING I N C I5.OU'fE12 CASING(for multi-cased wells)012 LiNER(li'Hill flle,Ible)
RROai TO DL\\II rrli TIIICK\1 SS n WERMI.
Company Name 0 r'' 70 rt' 6 io' PVC —`-
SW22-10062 16.INNER CASING OR TUBING mothermal closed-loop
2.Well Construction Pel•nlil!/: prtoal 7:0 n1ANT_'rIsR TIIICKNb:SS 11dTImlm,
List all applicallh,well can.rn retina perutiLr(i.e.U/C,County,State, 14a•ianct,etc.) ft. fl, in. --—
3.Well Use(checl(\yell use): _---
Water Supply Well: 17.SCREEN
❑Agricultural I+Boat ro ptnaua7sa SLOT SIZE. THICKNESS MAT1:RIAl.
❑MunicipaUl ublic ft. 1.1 ;,� --
❑Geothermal(Heating/Cooling Supply) n1tesidential Water Supply(single) _..
ft. fL in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑Irri'ation IS.GROUT
❑Wclls> IOO,000GPD FROM To MATERIAL EMI'L:\CEMrNTn7t:TIIOUS,\NIUf;N'I'Noll-Water Well: 0 r'' 20 rt GROUT POURED
❑Monitoring ❑Recovery ft. ft.
Injection 4Ve11:
DAquifcr Recharge ❑Groundwater Remedialion ft. ft.
❑Aquila Storage and Recover l9.SAND/GRAVEL PACK if a Itcnblc
Y ❑$flIlnlly BaI'I'ICf RltO\I I'Q n7ATIiR1AI• rM l'I,ACrnl r,,' +:r1IOD
❑Aquilcr'I'cst ❑Stormwater Drainage ft• ft.
❑Fxperinuentai'l'cchnology ❑Subsidence Control fL ft. --
❑Geothemtal(Closed Loop) I:11'racer 20.DRILLING LOG attach additional sheets if necessary)
L1Geolhamal(heating/Cooling Return) ❑Other(explain under#7.1 Remarks) FROM TO _uEs(:ItlFrION(color,hardness,soll/rocle trI e.drain sire,cic.)
11-7-2022 0 r`' 60 r'' DIRT
4.Uati Well(s)Completed: Wel ft.I IDII 60 505 r'• ROCK - � ,•. ;�; ;�
5u.Well Location: -
HICKORY WELL -
P;ncility/OwncrNi1010 Facilhy ID11(il':fppficnble) fl. ft.
217 SYCAMORE DR,NEBO,N.C. 28761 _ ����" "` '^�^�f•�L,��^�. Ina
ft, fL r.9p! ,;
Physical Address,City,and Zip fl, ft. -
MCDOWELL 172300155033 21.REMARKS
County Parcel Identification No.(PIN)
5b,Latitude and longitude in degrees/minutes/seconds m•decimal degrees:
61,well field,one lat/lonr is sufficient) IV
350 58.410 N 81033.684 / 22,Cet'tif' ition:t
11/7/2022
6.is(nrc)the wcll(s): MPermanent or ❑Temporary Signnture ofCenified Well Contractor c,. Date
Crs•igning thisfbrm,l hereby cervf/i,that the wcIl(.r)Iras(Isere)con.rtracted ill ac•rordoace with
7.Is this a repair to an existing well: ❑Yes or l'INo IS.'I NCsIC 02C.0100 ar iS.•I NC:•IC 02C.0200 II'el/Consnvctian S'tuntlart/s nud that o cops I0his is a repair.•lill oar knoua u'er/l c•attstruclia(t itl%armu(ion rail explain the nature oJ'the g0111s•record has been provided to the wed/ou.ncr.
repair under 1121 remarkssection a(on[lieback of dNs•form.
23.Site diagram or additional well(details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may tlsc the back of this page to provide additional well construction ill(b
consu'uction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'Sce Ovcr'in Remarks Box):You nlny also attach additional pages il'neeessaly.
drilled:_
24.SUBMI'I'TAL INSTRUCTIONS
9.'I'otal well depth below land surface: 505 (ft,)
For nndliple it-ells list all depths ff l?&I-eru(example-J n 200'and 2 100') Submit tills GW-1 within 30 days of well completion per the follo\ying:
10.Static water level below lop of casing: 90 (ft.) 24it. Fin• All Wells: Original Corm to Division of Water Resources (DWR),
/i'u•ruer level is whom casing,use•";" information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
11,Borehole diameter: 6 24b. For Infection Wells: Copy to DWR, Underground Injection Control(lUQ
Program, 1636 MSC,Raleigh,NC 27699-1 636
12.Well construction method:
(i.e.auger,rotmy,cable,direct push,etc.) 24e.For Water Supply find Open-'Loop Geothermal Return Wells:Copy to the
county environmental health(lepaltmcnt of the county where installe(I
FOR WATER SUPPLY WELLS ONLY: 24d,For Water Wells producing'over 100,000 GPD: Copy to DWR,CCPC'UA
13a.Yield(gPnt) 5 Method of test: AIR Pernut Program, I61! MSC,Raleigh,NC 27699-161 1
I
13b.Disinfection type: HTH Amount:
Porn(iNt-I North Carolina Deparrlment ol'linvironmendll Quality-Division of Water Resources 1
Revised C:G:.UIS