GW1-2023-00559_Well Construction - GW1_20230104

I
WELL CONSTRUCTION RECORD (CW-1) For Internal Use Only:
I.VVell Contractor Information:
CHAD HARTNESS
14:WATER ZONES,
Well Contractor Name - FROM '1'O DESCRIPTION
2901A 989 ft. 990 ft. I
ft. ft.
NC Well Contractor Certification Number
AIR DRILLING I N C l5.OUTER CASING for multi-eased wells OR LINER(if a licable)
FROM TO DL\METERI THICKNESS MATERIAL
Company Name
0 ft. 80 rt. 6 Inn. PVC
16.,INNER CASING OR TUBING 6othermal closed-lot
2.Well Construction Permit#: FROM I TO DIAMETER I I THICKNESS I MATERLII.
List all applicable well constriction permits(i.e.U1C,Coady.State,Variance,etc.) ft. ft. i in.
3.Well Use(check well use):
Water Supply Well: 17.SCREEN h
FROM '1'O DIAMETER SLOTSIZE THICKNESS I MATFRIA I.
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Hcating/Cooling Supply) iJResidential Water Supply(single)
❑industrial/Cominercial ❑Residential Water Supply(shared)
18.GROUT s
❑Iri ation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 tt. 20 ft. GROUT POURED
❑Monitoring ❑Recovery
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Rcmcdiation
❑Aquifer Storage and Recovery ❑Salinit Barrier 19.SAND/GRAVEL PACK if a licable
Y FROM I TO I MATERIAL EMPLACMMENTMETHOD
❑Aquifer Test OStormwater Drainage ft. I ft.
❑Experimental Technology ❑Subsidence Control
❑Gcothennal(Closed Loop) OTracor 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
0 ft' 70 f'• DIRT
4.Date Well(s)Completed: 08-22-2022 well ID# 70 ft. 1005 ft- ROCK
Sa.Well Location:
HICKORY WELL SERVICES
Facility/Owner Name Facility ID#(ifapplicable)
2854 NORTH FACE DR,VALDESE,N.C. 28690 ft.
Physical Address,City,and Zip ft.
BURKE 56265 21.REMARKS
County Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22 rtifi ton: `
35° 43.390 N 81 ° 36.243 w 8/22/2022
6.Is(are)the well(s): C]Permaneiit or ❑Temporary Signature ofCcrtified Well Contractor Date
By signing thisJorni,/hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or InNo 15A NCAC 02C.0100 or/5A NCAC 02C.0200 Well ConstntcHon Standards and that a copy
/f this is a repair,fill out known well construction information and explain the nature ofthe of this record has peen provided to die well owner.
repair under#21 remarks section or on the back of this forni.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop,Geotliermal 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'Sce Over'in Remarks Box).You may also attach additional pages ifnccessary.
drilled:
24.SUBMITTAL INSTRUCTIONS'
9.Total well depth below land surface: 005 ft
For n thiple wells list all depths ifdd(jerent(erample-3 a,200'and 2@100') ( ) Submit this GW-1 within 30 days of'well completion per the following:
10.Static water level below top of casing: 300 (ft 24a. For All Wells: Original,form 'to Division of Water Resources (DWR),
If water level is abom casting,use'+' ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
i
11.Borehole diameter: 6 24b.For Infection Wells: Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12, construction method: 24c.For Water Supply and Open-Lo Well o
augc
(i.e.augep'Geothermal Return Wells:Copy to the
r,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 GPD: Copy to DWR,CCPCUA
1 Permit P 16 ermrogram, 1 1 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:AIR I
I
13b.Disinfection type: HTH Amount:
I
I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources i Revised 6-6-2018
i
I