GW1-2023-00560_Well Construction - GW1_20230104

WELL CONSTRUCTION RECORll (GW 1) For Internal Use Only:
I.Well Contractor information:
CHAD HARTNESS
14.WATER ZONES
Well Contractor Name FR03I •1.0 DESCRIPTION
2901 A 4-0 fI• 410 fC J i
ft. B.
NC Well Contractor Certi ftcalion I
Number
AIR DRILLING I N C 15.OUTER CASING(for nlntlti-cased hells)OR LINER(if a licahle)
F720\I TO DIAMETER I{TEIt TIIICKNESS 111,\TERI,\L
Company Name
0 fl 110 rt 6 ` I in. PVC
16.INNER CASING OR TUBING eotherntat closed-loop)
2.Well Construction Permit It: FRO\I TO DIAMETER TIIICRNE.SS MATERIALLitt fill applicable irell c•onstrmci/ml permits(i.e.UIC,Coanryi s/roe•,14»•iaaee,ern) rt• ft. in.
I'
3.Well Use(check well use): fl. fl. i in.
Water Supply Well: 17.SCREEN `
❑Abriculllmll ❑Municipal/1l ublic FROdI _ 'ro DInk11:ER MATERIAL
ft. ft. in.
❑Gcothemtal(Ileating/Cooling Supply) IJResidential Water Supply(single)
ft. ft. in.
❑Industrial/Conn icrcial ❑Residential Water Supply(shared)
18.GROUT
Olt-rigation ❑WCIIS> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 - ft. 20 f' GROUT POURED
❑Monitoring ❑Recovery ft. ft.
Injection Well:
❑Aq uiferRecharbe i ft. ft.❑Groundwater Remcaton❑Aquifer Storage and Recovery ❑Salinil Barrier 19.SAND/GRAVEL PACK if a licable
y FROM To MATERL\L EMPI.AMMENTMI?T1101)
❑Aquifer Test ❑Slonnwater Drainage
❑Expeiiniental Technology ❑Subsidence Control
❑Gcothernal(Closed Loop) C1TiaCCr 20.DRILLING LOG(attach additional sheets if necessary)
❑Gcothemtal(Ilcating/Cooling Return) ❑Other(explain under/I21 Remarks) FROat TO DESCR11MON(color,hardness,sotUrock type. rain size,etc.)
0 "' 100 ft DIRT
4.Date Well(s)Completed: 10-28-2022 well iD/I 100 ft' 425 f' ROCK
5a.Well Location:
B. n. t p•.s I` 11 6
HICKORY WELL ft• ft. i -
Facility/OwnerName Facility ID11(ifapplicable) ft. ft.
IV Q
5368 DUCKWORTH LANE,MORGANTON,N.C. 28655 ft. rt.
• _....��, -•' tat.
Physical Address,City and Zip ft. ft.
Irk'"'- ri �juOt-:.•,,
B U RKE 55789 21.REh1AI2KS
County Parcel Identification No,(PiN)
5b.Latitude and longitude in degreeshninutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient)
22.Certification:
350 44.198 N 81049.513 Ni, r-
i '° - 10/28/2022
S , i re n Cc irtcd W•II o mclor "
6.]s(are)the well(s): ❑Permanent or ❑Temporary Dale
lly signing this•fm-n,1 hereby ccrl(/i,that the ivell(i)was 6rcre)coms7rucicd in accordance with
7.Is this a repair to an existing\yell: EIYes or t9No 15A NCAC 02C.0100 or 15A NGIC 02C.0200 Well Con iruction Sianelardr and dial a cagy
nfrhir record hers hee»
Ifthis is a repair,•frll one knoum well construction in/ornmaion and cspla/n the nature of nc� provider/In the ne/1 nw»er.
repair under/Ill remarkr seclio»or on the hock oJ'thir forme.
23.Site diagram or additional well.details:
S.For Geoprobe/DPI'or Closed-Loop Geothermal Wells having the same You may use the back or this pagc'to provide additional well construction info
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells (add'Sec Ovcr'in Remarks Box).You may also attach addiu'on51 pages if necessary.
drilled: '
24.SUBMITTAL INSTRUCTIONS
9.'I'otal well depth below land surface: 425
rornuhiple u•ellr list all depths dfd/{jerent(evangde-3(i1200'and 2 a 100') Submit this GW-I within 30 days of well completion per the following:
10.Static water level below top of casing:'50 (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
(fu'arer level is above rashkg.use'•i- Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
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.) 24c.For Water Supply and Open-hoop Geothermal Return Wells Copy to the
county environmental health depalltmf nt 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(gpm) 1 1/2 Method of test,Al R Permit Program,1611 MSC,Raleigh,NC 27699-1 6 11
13b.Disinfection type: HTH Amount:
Form GW-I North Carolina Department of Environmental Quality-Division or Water Resources Revised 6-6-2015