GW1--00592_Well Construction - GW1_20240118

. yy
'WELL CONSTRUCTION RECORD GW=1 Print Form
• - � • ) For Internal Use Only:
1.Well Contractor Information:
CHAD HARTNESS la:WATER ZONES_
Well Contractor Name I'ROM 'TO"o DESCRIPTION
2901A 21)9 rt. 290 ft. ,I
ft. ft. I ,
NC Well Contractor Certification Number
.15.OUTER:CASiNG(for multi-cased wells)OR LINER(if ap licable)
AIR DRILLING INC FROM_ •to^-''' '` ' DIA9IETERII' THICKNESS' MATERIAL
Company Name 0 ft. Ire ft. 0 f l9• PVC
16,INNER CASING•OR TUBING(geothermal closed-loop
2.Well Construction Permit#: FROM •; TO; DIAMETER' THICKNESS MATERIAL
List all applicable well canstrvcllon permits(i.e.WAC,County,Stale,Variance,etc.) ft. ft. (in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: •17,SCREEN.- •-
FROfrt ' '1'0 DIAMETER SLOT SIZE '1'111CICNESS It!ATRRI .
Agricultural 0Municipal/Public ft. ft. - • • In.
Geothermal(Heating/Cooling Supply) IEResidential Water Supply(single)
ft. ft. In.
Industrial/Commercial DResidential Water Supply(shared)
IS.GROUT - '
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. GROUT POURED
Monitoring 0Recovery ft. ft.
Injection Well:
ft. ft.A Aquifer Recharge DGroundwater Rcmcdiation 19,SAND/GRAVELPACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETI101
Aquifer Test DStormwater Drainage ft. ft. .
Experimental Technology OSubsidence Control ft. ft. '
Geothermal(Closed Loop) DTracer -20,-DRILLING•LOG(attach addltionafsheets if necessary)•
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) PROM t 0 DESCRIPTION(cuter,tinniness;soturoch type,grain size,etc.) ,
0 I. toe ft. DIRT
4.Date Well(s)Completed: 08-11-2023 Well ID# toe ft• 305 ft.
ROCK
5a.Well Location: ft. ft.
GALLAGHER,ROBERT ft. ft.
Facility/Owner Name Facility lDll(if applicable) ft. ft.
3316 JOHNS RIVER RD,MORGANTON,N.C. 28655 ft. rt. : El :; ' i Di
Physical Address,City,and Zip ft. ft. '"" �`�' ro ,. „
BURKE 63734 - 21.REMARKS . . •JA;N I li L(iLd
County Parcel identification No.(PIN)' y `'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ' ,r.''-:w nC C
(if well field,one lat/long is sufficient) 71. ertifi lion r<Th ice.
•
35°49.989 81° 43.051
N W ' °"".,--'---•.08-11-2023
6.ts(are)the well(s)rJPermanent or OTemporary Signaturc'of Certified Well Contractor Date
, By signing this form,1 hereby certify that the well(v)war(were)constructed in accordance
7.is this a repair to an existing well: DYes or ONo with 154 NCAC.02C.0100 or 1SA NCAC 02C.0200 iVell Consn•uclion=ltandards and that a
If this is a repair,Jill out known well caesu'uclion it fn•niatiaa and explain the nature oldie copy of this record has been provided to the well
repair under 021 remarks section or out the back of this forms.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land sur face: 305 (ft.) 24a. For All Wells: •Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiffirent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources Information Processing
If water level is above casing.Ise'•+" r Unit,
1617 Mail Service Center,Raleigh,NC 27699-1 6 1 7
11.Borehole diameter: 6 (in.) 24b. For Injection Wells: In addition'to sending the form to the address in 24a
12.Well construction method: above, also submit one copy of this fans within 30 clays of completion of well
construction to the following:
(ire,auger,rotary,cable,direct push,etc.)
FOR WATER SUPPLY WELLS ONLY: Division'of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 10 Method of test: AIR 24c.For Water Supply& Injection Wells: In addition to sending the form to '
the address(es) above, also submit otic 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 constricted,
Form OW-I North Carolina Deportment of Environmental Quality-Division of Water Resources Revised 2-22-2016
i