GW1-2023-00549_Well Construction - GW1_20230104

WELL CONSTRUCTION RECORD (GW 1)
For Internal Use Only: t ',
1.Well Contractor information:
CHAD HARTNESS
14.WATER'ZONES
Well Contractor Name FROM .1.0 DF,SCRIP'1'ION
2901 A 389 rt• 390 fc.
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased OR LINER(if a licable AIR DRILLING I N C FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 tL 80 fit' 6 in. PVC
06-2022-173719 I&INNER CASING OR TUBING cotllerntal closed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS
List all applicable it-ell conshvcvion permits(i.e.U1C.Coanty,State,V in
ariance,etc.) NATERL\MATERIALft. ft. .
3.Well Use(check well use): fit. ft. in.
Water Supply Well: 17.SCREEN
❑Agricultural FROM ro DIAaIpa'ER sLoTsizE 'I'll 'SS
Mnr1R1nL
❑Municipal/Public rt. rt.
❑Gcothennal(Heating/Cooling Supply) OResidential Water Supply(single)
ft. rt. In.
1 ❑industrial/Commercial ❑Residential Water Supply(shared)
❑lrri ation 18.GROUT
❑WC11S> '-O,000GPD FROM TO MATERIAL EMPLACEMENT DIET110D 3 AMOUNT
Non-Water 0 ft. 20 rt. GROUT POURED
❑Monitoring ❑Recovery ft fit
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation ft. fit.
❑Aquifer Storage and Recovery ❑Salinity Barrier 19.SAND/GRAVEL PACK if applicable)
FROM TO IATERL\L EMPLACEMENT M, IOD
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control fit. ft.
❑Gcolhcrmal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional°sheets it necessar
❑Gcotlicmial(Ilcating/Cooling Return) ❑Other(explain under Q 1 Remarks) FROM To IDEsclttrrloN(color,Ilariness,soffrock type.grain size,etc.
0 ft' 70 rt. DIRT
4.Date Well(s)Completed: 09-20-2022 Well 1D# 70 ft' 405 rt• ROCK
5a.Well Location: ft. ft.
., a
ALBERT YODER rt. r1. �;�• �'„..,��� � , .r
_.
Facility/Owner Name Facility ID/l(ifappiicable) ft. ft.
6722 JACOB DR,HICKORY,N.C. 28602 fit.
Physical Address,City,and Zip ft. fit. U;,+
CATAWBA 278114246363 21.REMARKS
County Parcel identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one]at/long is sufficient) i
35" 41.172 N 81 ° 25.008 2 ey ifiea✓';t:
..- .. /20/2022
6.Is(arc)the well(s): IJPermancut or ❑Temporary Signature of Certified Well Contractor 'Date !
Dy signing this form,l hereby certify that the wells)was(here)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or InNo 15A NCAC 02C.0/00 or 15A NCAC 02C.0200 11'ell Construction Standards and that a copy
If this is a repair•fill out known well construction itt/brmation and explain the nature of the of this record has peen provided to the well owner.
repair under 82l reanarkr section or on the back of this form.
23.Site diagram(Jr 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You dray also attach additional pages if necessary.
drilled:
24.SUBMITTAL"INSTRUCTIONS
9.Total well depth below land surface: 405 (ft.)
For nathiple wells list all depths ifdii ferent(u rantple-3 rt 200•and 1 ct 100� Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 70 (ft') 24a. For All Wells: Original form io Division of Water Resources (DWR),
1f uwter level is above casing,use"+^ Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
i ,
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: Copy to DWR, Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:
(i.e.auger,rotary,cable,direct push,etc.) 24e.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(gpni) 20 Method of test.AIR Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount:
I ,
Form GW-I North Carolina Department of Environmental Quality-Division or Water Resources Revised 6-6-2018