GW1-2023-00562_Well Construction - GW1_20230104

WE IA,CONSTRUCTION RECORD
For Internal lisc Only:
I.Well Contractor Information:
CHAD HARTNESS
14.WATER ZONES
Well Contractor Nnme FROM ' .1.0 DESCRIPTION
2901 A 289 rt, 290 It.
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NC Well Contractor Certification Numb It. ft.
er t I
AIR DRILLING I N C I5.OUTrR CASING(for multi-cased wells)OR LINER(if a))livable)
FROd1 'It) DIAMETER_ THICKNESS MATERIAL
Company Name 0 ft- 51 ft' 6 ' i" PVC
16.INNER CASING OR TUBING cothernial closed-loop)
2.Well Construction Permit It: PRO31 TO DIXmE'rER THICKNESS MATERIAL
List all applicable it-ell cou.rtrileflon perunls(i.e.111C,Coenl)a Spar, Nari+nrcr.rtc'J fL fl. in.
3.Well Use(check Yell use):. ft. rt. in.Water Supply Well: 17.SCREEN
❑Agricultural , FaoM _ r0_ utn.vn.rFa(_ SLOT SIZE THICKNESS .11ATE'RilA1.
[JMunicipal/1 ublic ft. ft.
DGcothermal(1•Icating/Cooling Supply) MIzesidenlial Water Supply(single) - - =--
1-1lnduslrial/Comm ft.
C1Residential Water Supply(shared)
1S.GROUT
❑11r1 rlWeils> 100,000 GPD FROST TU MATERIAL F,MPL,%CEMIiNTNt F:TIIODt-. AMOUNT
Non-Water 0 ft. 20 rr. GROUT POURED
❑n4oniloring CJRccovery f[. fl
Injection Well:
M uifer Recharge ClGroundwatcr Rcmcdiation
IJAquil'a'Storage and Recovery ❑Salinity Barrier19.SAND/GRAVEL PACK if a livable)
PROM 1'0 MA'rER1AL EMPLACIsatENThIGr110D
❑Aquifer hest 0Stormwater Drainage ft. ft.
❑1?xperinlcutal'l'cchnology riSubside»ce Control R, ft.
1_IGeothermal(Closed Loop) ClTracer 20.DRILLING LOG(attach additional sheets if necessary)
LJGcothernlal(healing/Cooling Return) 1"-:I0ther(explain under 1/2.1 Remarks) FROS1 TO DESCRIPTION(color,hnrdncss soil/recta hlre gndn size,cle.)
11-2-2022 o ft' 41 ft• DIRT
4.Date Well(s)completed: Well ID11 41 "' 305 rt ROCK
5a.Well Location: it. ft.
HICKORY WELL - rt. f1.
Facility/Owner Name I'acili(y[D71(il'applicable) ft. ft. •`:•� ��, y ',a J,,,,.,9.,..:
3240 ROCK CREEK RD,MORGANTON,N.C. 28655 f1.
Physical Address,City,and Zip ft. ft.
BURKE 2722327375 21.REMARKsITU1
County Parcel identification No.(PIN)
5b.Latitude and longitude in degreeshninutes/seconds or decimal degrees: ><_
(il'wcll field,one tat/loot,is sul'lieicnt)
35° 42.586 81 ° 36.681 bUrtirion:
N
11/2/2022
6,Is(are)the well(s): [!]Permanent or ClTemporary Signature acertr0ed Well Contractor Date
Bysigning this•Jbrna 1 hereh)'cerli/'that lire mell(s)was(here)constructed in accorr/aace with
7.Is this it repair to an existing well; ❑Yes or CI No 1511 NC4C 02C'.0100 or 15A NCAC 02C.0200 Mott Construction Standards and that a copl'
!fthis is a repair.•/ill out known"'ell cau.sn•uction ir(Jbrmalion and erphda the uutnre o/'the (Olds meord has been prol'ided to the n'el/owner.
repair under 1121 rentarks.section or nn the back etfilis•.form.
23.Site diagram or additional well details:
8.For Gcopr•obe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well const, Iction info
construction,only I GW-I is needed. Indicate TOTAL.N[JMBI.-,R ol'wclls (add'Sec Over'in Remarks Box).You may also attach additional pages((necessary:
dnned: _____
--- 24.SUBIWITTAL INSTRUCTIONS
9.Total well depth below land surface: 305 (ft.)
Ga•arldliple wells list rrll dePIAT/fdf&retl(crrinrple-3 cy200'and?(ti;/(1(J') Submit this GW-I lvithin 30 days of well completion per the following:
10.Static water level below top of casing: 70 (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
!f water level isahom rasing,list•"t" Information)'recessing Unit, 1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6
(in,) 24b.For Injection Wells: Copy to DWR, Underground Injection Control(11JC)
12.Well construction method:
Program, 1636 MSC,Raleigh,NC 27699-1636 i
(i.e.auger,rotary,cable,direct push.etc.) 24e.For Water Su 1 and Open-Loon Open4.00n Geothermal Relw'n 1Vells:Copy to the
county environmental heall t clepar'trnent of the county where installed
FOR WATER S[JfPLI'WELLS ONLY: 24d.For Water Wells»roducin�ovcr 100,000 CPD Copy to DWR,CCPC[JA
13a,Yield(gplil) 25 Method of test AIR Period Program,lhl I MSC,Ralcigh,(:NC 27699-1 6 1 1
131).Disinl'eclimt type: HTH Amount:
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Form GW-I North Carolina Deptnlnrent of Environmental Quality-Division of Water Resources I
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i Revised 6-6-2018
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