GW1--00648_Well Construction - GW1_20240119

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WELL,CONSTRUCTION RECORD (GW-1 �--- _ —
For internal Use Only:
1.Well Contractor Information;
r
CHAD HARTNESS I
'I4•WATER ZONES I I
well Contractor Name
TO DI•:SCltlh'1'IO\
ft. ____ ft. I I I
NC Well Contractor Certification Number I — —
AIR DRILLING INC IS.OUTER CASING(I'or multi-cascii Wells)OR LINER(ifapplicattte) —
FROM---IO DIAMETER THICKNESS JI.\'I'I RIAt_
Company Name 0 it1U'/ eh I. fu, ._..hVC
390395 16.INNER CASING OR TUBING(geothermal closed-loop) --" __�
2,Well Construction Permit II 390395 _DIAMETER. ruu:I:NRBS__._ an.rrf•.RI.\I. —
List all applicable well construction permits(i.e.WC,County,State,Variance,etc.) ILIt. 1 'in.
--- ...------ I. _._— _ -•I
3.Well Use(check well use): rt, ft. ! in.
rI Water Supply Well: 17.SCREEN ,
I Urlgrieu kural ) ruoat_ TotIASIIcrl•:a —sI drr SIZE 'it:ic:c •.ss__ matt' Rt,\�. —
Y DMunicipal/1 ublic ft._ ft. in, "
(ieothermal(llcating/Cooling Supply) XDResidential Water Supply(single)
:
— — — — - -- —•-- --_..._.__.._.. _
hid isirial/Coutnercial DlResidential\l ft. fhltcr Supply(shared) 1
IR.GROUT I. in.
!Irrigation fROMI Y'o Mtnrtin�,u__ Lin')�CtiMlG rat rnou&_�.�(u l:�l
Non-Water Supply Well; 0 R. J0 I'I. ONQur POURED
'Monitoring DRceovery 1't. f6 -- __. .
Injection Well: `--_ — — — — — —
/\(oiler Recharge fl. —^— ft. —
1DGroundwatcr Rcnudiation
;Aquifer Storage and Recover 19.SAND/GRAVEL PACK(if applicable) I
Y [Disability Barrier FROM To m•vrr:aiAt: rt\tpl.ACt an:y'r.\tI I lIta—_
A(uili:rTOL — -- ---
1 Osloru nitro Drainage It• I't.
Experimental'I'echnology DISubsidence Control -- rt. rt. i
-- —
Gwthcrnnd(Closed l.00 r)--^^�),
O [J'I racer 20.DRILLING LOG(attach additional sheets if necessary)
'(.;OUthel'»lill(Heating/Cooling Return) n011)el'(explain under 1121 Remarks) -FItoMI vl ) UIisCRll''I'IUN(color,hardness,soilh-ncl:h•tc,•;rain slrq etc. _
1.._,_................). .
It. 97 Il• Dllt"f �
4.Date Well(s)Completed: 6-16-23 Well IDII R. ff.——— �pP:^Ere. "_ -{
t)% 7.A5 ROCK I. 4 '; 1;y ry C
Sa.Well Location: • ft. ft—. -- i—, -----" `y''1.., 1 n"- )
TREXLER CONST rt. -- IL l; —JAN.1 -
Facility/Owner Name Facility ID/I(if applicable) 1'L; fl• I lil,Dri3V-10) Pr,,.,
436 AUTUMNLIGHT DR,SALISBURY,N.C. 28147 ft."' -n.^- —` -'- D ec:j OG'2 U
Physical Address,City,and Zip fl• fl. ,
ROWAN 458E003 21.REMARKS •
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County Parcel Identilicaliun No.(PIN) I
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ----.-- _ —'
Orwell field,one ha/long is sufficient) c. C rtiG �I C: on: --- _. .._._...
35°40.113 N 80° 33.075 E
6.'stare)the o'ell(s)�X II'cnnanent or ❑I'1'emporm•y Signature ol'Certiticd Well Contractor I` Duty
By signing this farm, I hereby rot*,that the well(s)till.('(wero)con.cn•ttelrrl in urrordaner
7.Is this a repair to an existing well: Dyes or DNo with/5:1 NCACOW.0100 or/5,4 NC'AC 0.?C'.0200 Well Construction Stamlardsand that o
1/'this is it repair,fill out kuoun well construction it(/brntation and et(/tluin the ua itre oldie cape of this record has Ite'en pruv(t/ed m i/n•well owner•
repair under tr 2/remarks section or on the back o/'this fia•m.
23.Site diagram or additional well details:
S.For Geoprobe/DI''i'or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well silt details or well
construction,only I CW-1 is needed. Indicate'I'O'I'A[.NUMBER of wells construction details. You may also a(l ich additional pages it'nccessat'y.
drilled:
--_-- SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 285 (fl.) 24a. For All Wells: Submit this;lot'nt within 30 days of completion of well
l•iu•multiple wells list all depths(f dillr'renl(example-3 q 200'mnl 2(i)l00')
construction to the following:
10.Static waterff level below top of casing;30 I: !
Ifiroi'rlocii.saborecasing.use"•," ( ) Division of��mler Resources,Inlinntnlliun Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-I617
I I.Borehole(li:unete,': 6 (in.) 241). For Iniection Wells: In uddiiiuit to sending the!irrm to the odtlrcss in 2 1.i
12.Well construction method: abo\'e, also sibmit one copy or this formwithin:to (lays of completion or itch
(Le.auger.curacy,cables direct push,etc.) construction Co the following: I i
I
FOR WA'1'IiR SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program.
1636 Mail Service Ccnt'er,Raleigh,NC 27699-1636
13a.Yield(gpm) 10 Method of test: AIR • 24c. For Water Supply & Iniectitin ilWells: in addition to sending the form to
HTH the address(es) above, also subniii (inc copy of this form within 30 (lays of
13 b.Disinfection type: Amount: completion of well construction to¢the county health department ur the county
where constructed.
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form CM-1 North Carolina Department of Environmental Quality-Division or Water Resources: R.a iscd: l r,2,1._2 ,
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