GW1--00604_Well Construction - GW1_20240118

WELL CONSTRUCTION RECORDGVI/-1 1 Print Form
For internal Use Only: ,
I.Well Contractor Information:
CHAD HARTNESS
14.WATER ZONES
Well Contractor Name mom 'I.0 DESCRII''I'ION
2901A Ng ft. ago ft. 1 ------
NC Well Contractor Certification Numb ft. ft.
I .
AIR DRILLING.INC 1S.OUTER CASING(for multi-cased wells)OR LiNER(if op Iicable)
FROM TO DIAMETER TIIICKNESS I MAMMALCompany Name 0 ft. all ft. I 6 In. If —
PVC
W546 16.INNER CASING OR TUBING(geothermal closed-Ianp)Well2, ell Construction Permit II: FROM TO DIAMETER TIlICKNESS MATERIAI.Lis/all upplic•able well construction permits(i.e. WC.Gaunt.5mw Variance.etc%) ft. ft. in. — "—
3.Well Use(check well use): ft. ft. in. —
I 'Water Supply Well: 17.SCREEN
I yl\�I'ICLII(lI i';11 mom To DIAlurnoi SLOT SIZE 'I'111CICNESS AIATER IA I_
r-- DMunicipal/t ublic It ft. in.
01111 Geothermal(Ideating/Cooling Supply) XDResidcntial Water Supply(single)
ft. ft. in. -'IleIndustrial/Commercial DResidcntial Water Supply(shared)
•• 18.GROUT
Non-Water
FROM TO Mr\'rERL�I• EMPLACEMENT moutonR,\\lOUNT Non-Waler Supply Well: 0 ft. 20 ft.
,Monitoring GROUT POUREDRecovery ft. ft.
Injection Well: __
!Aquifer RStorage
JGroundwater Remediation ft. ft.
Aquili r Slnragc and Recovery19.SAND/GRAVEL PACK(if applicable)
QSalinity Barrier FROM TO \1A'1'ERLIL EMPLACEMENT METHOD
Aquifer"Test DStormwater Drainage ft. ft.
Experimental Technology .- QSubsidencc Control
1It. rt. — "— —
Geothermal(Closed Loop) D'1'racer 20.DRILLING LOG(attach additional sheets If necessary)
Geothermal(I leafing/Cooling Return) n101her(explainlunder l/21 Remarks) Flaunt ro DEsctitp l'IOr(enter,I,ordnes,.owl<O soil/rack grat,+,l..e. e.)
o rt. �o rt. D1Irr —
4.Date Well(s)Completed:'07-1 8-23 Well ID/1 7o ft* sus ft. --
ROCK ;
Sa.Well Location: ft. ft.
DONNIE HICKS R. ft. •
Pacilily/O+vner Name Facility ID/i(if applicable) ft. • ft. , "' da..8 e�
80 SIMMONS RIDGE DR,TAYLORSVILLE,N.C. 28681 ft. rt. ,fAN 1 ;es
1 n24
Physical Address,City,and Zip ft. ft. --"
ALEXANDER 21.REMARKS In-or "C +'ia::.,:;i<:G; ,g,U.4q4
LIWC eS'VLry
County Parcel Identification No.(PIN) .--..__
—
;b.Latitude and goal ilude'its degrees/minutes/seconds or decimal degrees: - !--
Orwell field,one ImIlona(is suflicieat) fifiea 'a:
35° 50.322 N 81° 16.728riy
W �• 182023---
6.Is(are)the well(s)�X IPerniancnt or DI'1'emporary, Signature of Certified Well Contractor Date
By signing this form, I hereby cevtifi'that the well(() WM(,rev'&Ca,cln,clud in accordance
7.Is this a repair to nit existing well: DYes or f No _ with MI NCAC 02C.0/00 ar i54 NCAC 02C.0200 IVell Constructive,Standards and that a
!Phis is a repair.fill out known well constructio,r inlinmation and explain the nanny o/•[he "AP of l/,m record has been provided to the,yeti on'ner•,
repair under IL?'remarks section or Oil the back o/'this fors,,.
23.Site diagram or additional well details:
You may use the back of this page to; additional well site details or well
S.For Ceoprohe/DP'1'or Closed-Loop Geothermal Wells having the same
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:. __- __
-..-—,-.—.-- SUBMI'1'77U,INSTRUCTIONS
9.'fnlal well depth below land surface: 605 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple,re/Lc list all depths ifdi(livent(example-3(t 200'and 2@/00')
construction to the following:
80
It).Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
!/•,ruler level is alum.casing,use"I"
' 1617 Mail Service Center,Raleigh,NC 27699-1617
I I.Borehole diameter: 6 (in.) 241). For infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: above, also submit one copy of this f(inn within 30 days of completion ofwell
t i.e.auger,unary,.able direct push,etc.) coustraetion to the!following: .
Division of Water Resources,Underground Injection Control Program,
hOR 1\'A'l'I':R SUP PIN WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 5 Method ol'test.: AIR 24c. For Water Supply& Iniection Wells: In addition to sending the form to
HTH the address(es) above, also submit one copy of this form within 30 days of
131).Disinfection type: Amount: completion of well construction to the'county health department of the county
where constructed. I
I
Form(iW-I ,Noah Carolina\Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016