GW1--00580_Well Construction - GW1_20240118

• :Print Form .
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
•
1.Well Contractor Information:
CHAD HARTNESS 1
14.WATER ZONES • I -
Well Contractor Name FROM _PO DESCRIPTION
2901A 409 ft. co ft. ,
ft. ft.
NC Well Contractor Certification Number
- 15.OUTER CASING(for multi-casedhvells)OR LINER(If np Ruble) '
AIR DRILLING INC FROM TO DIAMETER . THICKNESS 1 MATERIAL
Company Name 0 ft. 37 ft. e I In. GALV
06-2023-197892 16.INNER CASING OR TUBING( eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits(i.e.U/C,County,Stale, Variance,.etc.) ft. ft ! In,
3.Well Use(check well use): ft, ft. in.
Water Supply Well: _17:.SCREEN
• FROM '1.o DiAME't'ER SLOT SIZE THICKNESS MATERIAL.Agricultural t,Munici al/Public ,
5--�f P ft. ft. in. ,
Geothermal(Heating/Cooling Supply) oResidential Water Supply(single)
ft, ft. in,
Industrial/Commercial DResidential Water.Supply(shared)
18.GROUT
irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 rt. 20 ft. GROUT POURED
Monitoring ORecovery ft. ft. '
Injection Well:
ft. ft.A Aquifer Recharge DGroundwatcr Rcmediation Aquifer Storage and19:SAND/GRAVEL PACK(if applicable) -
Recovery
q g OSalinityBarrier FROM TO - MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage - ft. ft.
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) OITracer '20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) F Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,solt/racit type,grain size,etc.)
0 ft. 27 ft. DIRT
4.Date Well(s)Completed: 08-21-2023 Well ID# 27 ft• 425 ft.
ROCK
5a.Well Location: It. ft. O
RICHARD KEISTER rt.
. ft. n E:--. e hr—Li
Facility/Owner Name Facility lDll(if applicable) ft. ft. I Q L02�
4926 RIFLE RANGE RD,CONOVER,N.C. 28613 ft. ft.
Physical Address,City,and Zip • ft. ft. flliirY��:i fl r f.^.. ;.ij;? URN
CATAWBA 373416821674 ,21,REMARKS "�i'a
County Parcel Identification No.(PIN)"""
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) a$ertifi on: �35°46.229 81° 13.872 f �N W .1' ,t,
. i
08-21-2023
6.Is(nre)the well(s)0Permanent or Temporary Signature of Certified Well Contractor' Date
? By signing this form,I hereby certt/jj'that Uie well(s) was(were)consul raid in accordance
7.Is this a repair to an existing well: DYes or ONo with I5/1 NC4C 02C.0/00 or 154 NCAC 02C.0200 1Vell Construction=dards and that a
If this is a repair,Jill out known well construction it f u•nwtion and explain the nature of the copy of this record has been provided to the well owner.
repair under 112/remarks section or on the back of this form.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL,NUMBER of wells
drilled:
• SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 425 (ft.) 24n. For All Wells: Submit this foitn within 30 days of completion of well
For multiple wells list all depths ifdiffirent(example-3C)200'and 2©!00') construction to the following:
10.Static water level below top of casing: 50 ft,
( ) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b. For infection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
1
13a.Yield(gpm) 5 Method of test: AIR 24c.For Water Supply&Infection Wells: In addition to sending the form to
the address(es) above, also submit one;copy of this form within 30 days of
13b.Disinfection type: HTH Amount: completion of well construction to the county health department of the county
•
where constructed.
Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016