GW1--00651_Well Construction - GW1_20240119

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WELT,CONSTRUCTION RECORD (GW-1) For Internal Use Only:
I.Well Contractor information:
CHAD HARTNESS I -
14.WATER ZONES I i
Well Contractor Name FROM '1'0 DESCRIPTION -
2901A 229 rt. 230 ft. I • --
ft, ft,
NC Well Contractor Certification Number
. 15.OUTER CASING(for multi-casediwclls)OR LINER(if ap Iicable)
AIR DRILLING INC FROM TO DIAMETER I TiIICKNESS ') MATERIAL —
Company Name o ft. 125 ft. 0 I in. • PVC
—
394186 16.INNER CASING OR TUBING(geothermal closed-Map) •
2.Well Coast action Permit II: FROM TO DIAMETER i _ TIIICKNESS MATERIAL
List all appileablr sell eoustrvaaion permits(i.e.WC',County,Slane, Variance.etc.) Ft. ft. 4 in.
—• 3.Well Use(check well else): ft. —ft.— j in. --
Water Supply Well: 17.SCREEN
FROM TO D1AM Ist'RR I SiOT•SIZE •ri IICKNESS nIA7_RRIAI_
p'Agrieulturral Municipal/public ft. ft. in.I
Geothermal(lleating/Cooling Supply) 0:Residentittl Water Supply(single) ft, ft. in.'
Industrial/Commercial Q Residential Water Supply(shared) 18.GROUT
1.
Irrigation _FROM _ro ___MATERIAL EaIPLACEMI;\"1'ME'rIIODR AMOUNT
Non-Water Supply Welt:. 0 fl. 20 fl.
GROUT POURED
Monitoring �RecovcrY ft. R.
Injection Well:
Aquifer Recharge ft. ft.
9 6 •
DReeovdwalcr Rcmc(liution •
19.SAND/GRAVEL PACK(if applicable) \
Aquifer Storage and Recovery Q Salinity Barrio FROM TO _ MATERIAL EMPLACEMENT METHOD
Aquifer Test �Slormwaler Drainage ft. ft. J
Experimental Technology Control R. n. ! —
I
Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal I ICatlll?/C001111,Return) FROM TO DESCRII''I'ION(color,hardness,soillrnca type,aratn size,eIc)
( t n Other(explain under 1121 Remarks)
0 it• 115 ft• DIRT
06-29-2023 •
4,Date Well(s)Completed: Well ID// 115 ft• 245 ft' ROCK ; ' �'`'' •
Si.Well Location: ft, ft. I' ✓, `�_L.'•_� -d ,� :.'rr-`a
RANDY LINK ft. — A_It: I --- '-•.:, 4,,,,�
Facility/Owner Name Facility Mil(if applicable) 1•t' ft• 1 JA,v 1 z024
1860 AMITY HILL RD,CLEVELAND,N.C. 27013 ft. ft. i In-f3m24jon fir_,•�^
Physical Address,City.and Zip �fl It. •
Dt C,1," 0rjljPr �
ROWAN 277002 21.REMARKS
County Parcel Illentilicatlon No.(PIN) —_--- I _...._�
Sb.Latitude and longitude in degrees/tuinutes/seconds or decimal degrees: !
(il'welt field,one lal/long is sufficient) 27titica'r ):
350 43.224 80° 43.277
i
6.Is(are)e)the well(s)�X Permanent or 1Tempor:n y Signature of Ccr ified Well Contractor - ;. • Date
By signing this form, I hereby call/b that t the well(,)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or ONo with 154 NC/IC 02C.0/00 or:ISA NCilC?02C.0200 Well Construction Saidarels•and that a
•"(thisisa repair,lilt out know:well consa•uc•tion do/iunwtinn and explain the nature of the cop nf s' this record has•been provider[to the:well owner•
repair under/12!remarks section or on the back o/'Ibis•.loam.
23.Site diagram or additional well'details:
S.For Geoprobe/DP'1'or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only l GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:,,.___, SUBMITTAL INSTRUCTIONS
9.'I'oLd ft well depth below land surface: 245 j' '
( ) 24a, Fo' All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifali(Ji•ren!('example-3(irl,.,00'and 2 l00') I
construction to the following: ;
10.Static water level below top of easing: 40 (ft.) Division of Water Resources,Information Processing Unit,
',limier level is above casing;use"(" 1617 Mail Service Center,Raleigh,NC 27699-I617
j,
I I.Borehole diameter: 6 (in.) 241), 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 SUP PIN WELLS()NIX: 1636 Mail Service Center,Raleigh,NC:27699-1636
I3a.Yield(gpnt) 5 Method of lost: AIR 24c. For Water Supply& infection Wells: In addition to sending the form to
the address(es) above, also submit ottc copy of this form within 30 days of
13b.Disinfection type: HTH , Amount: completion oI'well construction to the county health department of the county
where constructed. I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources i Revised 2-22-2016
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