GW1--00714_Well Construction - GW1_20240119

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
I.Well Contractor Inl'orntalion:- .
CHAD HARTNESS
14,WATER ZONES I ' ----
WelfConlrtctorName FROM T(I_ ursc•Ittril10N
901 A _._- _
oat) I'1• ago ft• .
•------__--.---• -_ --.-
NC'Well Contractor Certification Number I'1' n.
AIR DRILLING INC 15.OUTER CASING(for multi-casedlwills)OR LINER(trap_licabte)
__I ItUA1_ _To _ _ Dts\IF:I'FR THICKNESS \1A'I:ER \I.
('un ,:u,g NI,,,,,, • U a1 ft G..._._..._ !u• V.
2023-24958 Ifi.INNER CASING OR TUBING(gebtlierntal closeddoop)2.Well Construction Permit//: raOA1 ro
—
l.i.rr dl1 u,,' / (: ..-..---• _,_.__ pl.\Alt:rt•:II __ '1.111CI:NKSS Aq,.12:IAI,
// ) fl. ft. i i
n.,
3.Well list`rCheticl\Yclltttrsr`tinn n•rnutt' t,'. (!I(..',Camay,Shur.Variance.er• ft. in.
)
n.
Water Supply Well: 17.SCREEN I
�r\(ricultunl [UMttnicipal/Public irRom) Tc ntnnrr.rl•:11 l,_xl.orsl"(:!2.--nncP:Nr.Ss-...at.crr_itl,u.
- - . -- ---
•
Geolhertnal(heating/Cooling Supply) XQiResidential Water Supply(single) rt. R. ���.
'lndust'ittVCotnt i'eittl []IResiclenlial Water Supply(shared) 1&GROUT
Irrigation / Ir5QM _ 'f0_ A7,\'1'ERL. EAII'1..\Ctimil\'I'mfhl'IIOU.I'•\AIUUN'1'
Non-Water Supply Well: ' _0 fL zo ft, - -
.'/'
GI1UUl' �:�— POURED
'Monitoring --------- -- -
�Rccovcry ft. rt. _._
❑jection Well: _
Aquifer Recharge �Groundwala'Rcmaiialion tI ---_ ft.
IAquil'er Storage and Recover19,SAND/GRAVEL PACIC(il'npplicalile)
Y �Stihll sly 13arrier7--
mom TO __ M,vrenr!__ 1':A
I t I'LACIAI EN'I'_1Ilr_r11ot) ..
'Aquifer Test Q15tormwitter Drainage I'1 n. i,tF
,Experimental'l'celtnolog!y ---- --------_ _--- I--------_.-__ _•- -.... ---
DSubsidencc Control rt. n. I i'
'Geothermal(Closed Loop)1 D.fracer 20.DRILLING LOG(attach addtlienufshcels If necessary)
Gcothca'nutl(I luting/Couliug (eltu'n) �Iplher(explain under i121 Rcntarks) '�u)' ' -.It.
-__-- -u1_...... ION(n.mr,hardness,..,Panel:-l)ge,grain n a7.e.tic.)
0 I J1't. I't. DIMr
07-07-23
•.Date Well(s)Completed: Well 1Dll I y1 I'I. i ' 1't. Hook j,
'a.Well Location: ft. ft.
- — ..
I
NAOMI ABEL — — — .—< __ ....
-- rt. rt. I�_ A. ..
—--- -- --- • `. 4 fir.�"" f a"
G3 c-) .
Facility/Uwucr Name Facility Mil(il'xpplica),)e) rt. rh Sr„�,,
182 QUAIL RIDGE DR,MOORESVILLE,N.C. 28117 n ft. I'li - cif\7 =\ z4
Physical Address,City,and Zip fl. fl in ..,....„;—"--
(vec �?7 fir..
IREDELL 21.REMARKS t.•• "'4645399355 Fit',.ry'r�n,ti >✓ 3
County Parcel Identification No.(PIN) -
513.Latitude:and longitude in degrees/minutes/seconds or decimal degrees: /.
(il'wen licld.one hu/tents is sufficient) Cart iett �� ,4"i•` — ---.-..---_
35° 32.491 80° 52.090 ( f% ° -, -J !' '
N \\,t-=_i, Uv i6 c -
I; 7-7-23
6.Is(are)the well(s)jX Permanent or QI'1'ompora•y signature ofCortilicd Well Contractor I Date
I'
lid signing this Jim», /hereby(.01 Ji'dial Me well(s) uns fume)c•Uhsi'ncied in ur-r•nr,lmrce
7.Is this a repair to an existing well: 0Yes or DNo n•irh /5.4 NOW O.KC.'.010(1 ur MI NC'rIC 0?C:.0.10(1 tI'e!!Construction Standards and that a
I/-this is a repair,,lill am known wellranstruclion!r fbrntu(iun and/explain ile'nature rf'th' ruffrf this record has(tic,:prot'idt'rl to/be ire!owner.repair under n 21 remarks sectou Ur WI t (Ma he bu n/l/:ls,/ohm.
23.Site diagram or additional troll details: '
5.For Ccuprobe/i)i"i'or Closed-Loop Geothermal Wells having the Santo You may use die back Or[Ilk page In provide additional well site details or well
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells eonslruetton details, You clay also attach pages ifneeessury.
drilled:
SU13M1'I"1'A1:INSTRUC'1'IONS �'
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9.'I'olal well depth below land surface: 405 •
(tt•) 24a. 11m All Wells: Submit this loins \within 30 days of completion of well
Par multiple wells list all depths ifdlli're,a(rxanrple-3(ir)2.00'mu!2@r),100') II
construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resiturccl,Information Processing Unit,
Orator level is a/sic'ra.rin,�,use"R" 1617 Mail Service Center;Raleigh,NC 27699-1617
11.Borehole diameter: 6 P
(ln.) 24b. For Injection Wells: In additions to sending the )brut to the address in 24a
12.Well construction method: above, also submit one copy of this fora within 30 days of completion of well
(i.e.nutter,rotary,cable,direct push,etc.) constmetion to the Ibllowjng: i
Division of Water Resources,Underground Injection Control Progra to.
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 2769 9-1 63 6
I3a.Yield(gpm) 30 \7clho(t of test: AIR 24c. For,Water Supply & Injection Wellls: In addition to sending the brut to
the address(es) above, also submit otie 'copy of this (boo within 30 days of
13b.Disinfection type: HTH Amount: completion of well construction to the'county health department of the county
where constructed.
Porm(i\\'-I North Carolina Department ul'linrironn,ontal Quality-Division ul'Naer Resources
Revised 2-22.2
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