GW1--00542_Well Construction - GW1_20240118

N/I,LL CONSTRUCTION RECORD .C;W-I I. i .
• hqr 1nit:rnal Use Only:
I.Well Contractor Information: 1
• CHAD HARTNESS J
t
Well Contractor Name14,WATER ZONES . _ 1 • - •
•
:mom TO DIiSCatttr'ION 2901A
. 369 • fl, 370 ' ft. -- , . ------
NC Well Contactor Certification Number fl• fl. ------..-. .__
AlR DRILLING I N C IS.OUTER CASING(for multi-cased wells)OR LINER(trap tlleable) — -
FROM TO nl,\mr:Ttilt: THICKNESS \ln1•rltt,\L
Company Name 0 I'L 1 18 ILI6 j iii.; �— PVC
• 2,Well Construction Permit 8; 1 984.81 16.INNER CASING OR TUBING(geothermal closed-loop) --`"
FRO\7 TO DIAMETER '1'IIICKNESS MATERIAL
List all applicable Iron c•onsir:aliw,permits(i.e.1/1C,County.State, Parlance,etc.) ft. ------
ft. 'in.
. 3.Well Use(check well use):
ft. fl. in.
Water Supply Well: 17.SCREEN r _
1:;:\,;rice htllntl ❑Male lelpal/public pROSI TO --- DIAMETER' SLOT SIZE THICKNESS lCK\t•:SS .\IA'I•I RILL -
i '(;col hermaI(I Ieating/C:uuling Supply) In Residential Water Supply(single) •--- ft IL — ^-in.,.-—
! !Industrial/Commercial rl' f! in•;, i
I:IResidenlial Water Supply(shared) -_�
;Irri)tnliufl IH.'GRUU'I' - —
CI4Vcllx' I UU,000 GPD mom TO '
Nun-Willer Supply Well: MATERIAL EMPLACEMENT Mu•:Tuuu.e AMOUNT
flMoniitter 0 fl• 20 fL GROUT POURED
17Recovery ft, ft. -- - —Injection Well: • •
. I.IAquifi:r Recharge LIGround\'atcr Remediation ft.
LlAquirer Storage and Recovery I ISnlinity Barrier ram! TO - \'I 19.SAND/GRAVEL PACK(\IAT'I'ERtAERIA lc)
t I?\II'L:\(:G\IGN'r\1li l'IIOU
!ar\i)uil'cr'I'( l ❑Stormtyater Drainage I't. ft. -__._.._...._
`ll xperimi:ntal Technology OSubsidence Control
ft. fl.
OGcotltermal(Closed Loop) 1J9Yacer 20.DRILLING LOG(attach addltiomil sheets if necessary)
l.-IGeolhermal(I leating/Cooling Return) f lOther(explain under 1121 Remarks) JtRO\I TO _DESCRIPTION(ester,hardness,soivrecic iy>s,'rain size,sty_)
. 16._
0 r'' 108 IL DIRT
4.Dale\Vell(s)Completed: 03-20-23 __-_— _ -_---------.--...__ I
Well lDil 108 rl,• 385 ri' ROCK I: ,
a.Well Location: " ft. ft.
;..:5 •�_�a
ANDREW ZALENSKI fL ft. a T - -------- .
Facility/Owner Name — — - J1A
Facility UM(if:,plic:,blc) rt. ft. . `�
125 'KERR LANE,ADVANCE --- �02�_.._.___ -
,N.C. 27006 rt. ll ,, P2�`��,,...
I'hysiral Andrei,.('ity.and Zip — - _•... _;« (h 7
II. I. Gibt,;3J��,
DAVIE . . 5863712007 . . 21.REMARKS
County • Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds o decimal degrees: --- - - :.. ...__--
il'well field.one I:nllon}!is sul'liciunl) aa) `---1 #§ 1
36° 10.356 80° 27.818 •
2 ,erlir)r�tiDn: �( ,
N ' , ,
W 4.<,. . - ,, -, ,•.� �..._ ' 3/20/2023
6.Is(are)the well(s): I!)Permanent or :❑Temporary
Signmurc ofCertifcd Well Contractor ,' Date
By signing lhi.sforvu,I hereby emit'.that die well(s)was(,sere)constructed in accordance with
7.Is this a repair to:On existing well: El Yes of IJNo IS,)MCA'0,?C.0100 or 1.5.4,VL':IC 02C,0200 Well Cansrr,rc•tion Solution's aml that a sops
IONS is a repair.fill out known well construction inThrmation and explain the nature oldie ' ,off/tls record has here provided to the weft ownc r.
repair under n:21 rentarls.section or on the back of this fire,.
23.Site diagram or additional well,detttils:
S.For Geoprobe/UP•1'or Closed-Loop Geothermal Well having the same You may use the buck o I'this page to provide additional well construction in lb construction,only I OW-i is needed- Indicate TOTAL,NUMBER or wells (add'See Over'in Remarks Box).You may also attach additional pages if ieccsary.
drilled:,,
24.SUBMITTAL INSTRUCTIONS,
- 9.Total well depth-below land surface: 385 (fl,)
•
/hsrler/tip/v wells list all depths.i/diferent(rraatple-3b)?Iltl'and.?(100') SubmitthisGW-1within30da)'sdl'\vellcompletionper(heItillotcing:.
10.Static wafer level below lop of rasing; 50 (fh) 24a. For All Wells: Original form•-to Division of Water Resources (DWRI.
It,rarer less I is above ru.tlli ,use •-' Information Processing Unit, 1617,MSC,Raleigh,NC 27699-1617
•
I I.Borehole diameter: 6 (in,) 24b. For Injection Wells: Copy to I�)WR, Underground Injection Control (ILK')
Program, 1636 MSC,Raleigh;NC 27699-1636
•
12.Wellconstruction method:
(i.e. c'!t rotary.cable,dime push.etc.) 24e.For Water Supply end Open-LoopGcDlhernunl facture Wells:Cory to the
county environmental health department orthe county where installed
FOR WATER SUPPLY WELLS ONLY:
24c1, For Water Wells producing over 100,1)00 GPD: Copy to DWR.('(.'PC'U,\
13n.field(gent) 30 Method attest: AIR •Permit Program, 161 I-MSC,Raleigh,INC 27699-I61 I -
13b. Disinl•eetitn type: HT H Amount: •
Form OW-1 North Carolina Department of Environmental Quality-Division ul'Water Resources
` Revised-6-6-20 l s
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