GW1--00715_Well Construction - GW1_20240119

MIA,CONSTRUCTION R14,C012.D GW-1 Print Form
IFor'Internal Use Only: '
I.Well Contractor Information:
CHAD HARTNESS _ I
•WellContractor Name I4,WATER ZONES I
FROM 1
.,TO n6SClil1''I'10\
2901A 409 ft. 410
I, t
N('\Nell Contractor Certification Number fI. ft.
I ( -^ - —
�.1
AIR DRILLING INC OUTER CASING(for multi-eased,Wells)OR LINER(Rap licable)
.121.t95.
Company Name R. 5tl ft. 0 I' in. PVC
z.Well Cnnslrnctinn Permit!/; 16892-2023 16.INNER CASING OR TUBING(geothermal closed-loop)
IRO\1- - - D1A\III It I'f IIC:I<V(:SS_ MATERIAL
/.ix!all applicable well construction permits(i.e. U/('.Comer.Stale, hit•iancr,etc.) .... .'_..__r... __Aral._-�--_--• --_ --.
ft. ft. I, in.
- --
rt. ft. nt.
3.'\\tdl Use(check well use): ( _-_---
Water Supply Well: 17.SCREEN -
I
{r\ ricul ltral r• _ ?Atom• .-- L_O_• DIAMETER SUIT SIZE_ TRICt<NFSS _\IA_rr_RIAt_[Municipal/I ublit: rt. rt. hi.
-. -
i'�
Geothermal(Pleating/Cooling Supply) XDRcsitlential'Water Supply(single) -------'-------- ---.--
In(lustrial/C•ommercial ORcsjd fly ft. in. _ - -
enljal Water Supply(shared)
hriy allot IS.GROUT
. t'(t0.�1—_ .;T(1_ _ �ht'rlili);u: r\u9 tCr,\tf:V•r\u•:'nlou CnAloUN'r
Non-Water Supply Well: fl. 2.0 ft.
cltour POURED\9onitorin Recovery
o
Injection Well: f,, I.' _.._-.---
---._...__..--• ----
r
l/\yuifcr Recharge Q,Grountlwutcr Renutlialion It. ft. -__ -L-_.--- ----- . --- -- -
D
IAguif'or Storage and Recovery [Salinity Barrier
IS.SAND/GRAVEL PACK(if applicable)
41(U\I ToMATERL\I!. t: ET
\1PI.ACEMENT\1ooD
guiler Test DSlornwvater Drainage ft. ft.
I --
13xperin)cn101'I'eehnDlD'=v Q Subsidence Contaf _.rft. ft. -- ;--- _-.. - ._-----________
Geothermal(Closed Loop) \'racer ; /
_0,DRILLING LOG(attach additional sheets if necessary)
Geothermal(Pleating/Cooling Return) Other(explain'under i/21 Remarks) Irl4O\I ._. _70 DIiSC'Itll1'1O\`(color,h:vdnccz,sniltnwl:type,grainsizes etc.)
07-03-2(113 -
•1.Date Well(s)Completed: Well IUN na ff• - ft. -
• nzs - Itocl<
5a.\Yell Location:
_ ._ ___ .._ _ ... --..__..__-
ahon: It. - -
•
LAKEMIST HOMES - — - - ... -- = -iL- - --
PncililylOwner N;mte tea
14iciliiy IDii(ifappticable) fly ft.
152 RYLEIGH DAN, MOORESVILLE,N.C. 28117 R. ft. I: ��1�� EG24 -
Physical Address,City,and Zip __
ft. ft. ---; �n vi ri'r:(�7��r.^M,1
IREDELL ��
4654791369 21.RE;\IARKS • I' , wi}vCd;
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ,. . -
.--.-._.._ _
(ii well filth.one laf/long is sufficient) '4 ---- - - - _-_..
u .�2. crfion:�"v
35 31.197 80° 49.522 (
•- 7 - 07-3-2023
G.Is(acre)the wcll(s)�X lPerHouten( or ❑I'I entpor:ry Signature ofCordlied\1'cll Coptraclor Date
By signing this•/brni, I here•hr cerliii'that the well(s) was(weer)constructed in accordance
7.Is this a repair to an existing well: Q Yes or El No I ( ... with/S,I NC'AC 0.?C•.0/00 or/SA NC}IC(E '.O.'00 It'll C'unsil•uci/onW'lm;darrtc and that a
If this is a repair.fill out known well construction in/banal/on and e.tplain the naunr n/7h(• c•o/m(?f his rc•r•urd hex been prong/e•rl In the ti•c•ll owner•
repair under i17!remarks.rect ion or WI the hack of this firm.
23.Site diagram or additional well details:
S.For Geuprobe/DPT or Closed-Loop Geothermal Wells having the same You nary use the back of ibis page toprovide additional well site details or well
construction,only I G\V-I is needed. Indicate TOTAL NUMBER of wells construction details. Youmay also attach additional pages tI tceccssary.
drilled:
•
SUBMITTAL INSTRUCTIONS
•
9.Total well depth below land surface: 425 I.
�raymab/ph•wellslistalldrya/isifd/(jc'rcna(example•.11(5700'and 14@)00')
cons
(ft') 24tt. For All Wells: Submitthis Turin within 30 clays of completion of well
construction to the following: I
10.Static water level below top of ruin(: 50 I;
(f water level isabnreeasing,use"r (IL) Division of Water licsnurccs,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
1 I.Borehole diameter: 6 (in.)
24b. For Injection Wells: In addition ito sending the form to the address in 2'fa
12.Well construction method: above, also submit one copy of this foini within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction In the following:
FOR WATER SUPI'L1'WELLS ONLY: Division of Water Resources,UndergroundInjection Control Program,
1636 Mail Service Cenlci•,Raleigh,NC 27699-I63G
13a.Yield(gpnt) 15 IVlethod or lest: AIR 24e. For Water Supply& Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days al
13h.Disinfection type: HTH Amount: cutup letlon of well construction to the ctiunty health department of the county
where const•tictctf.
Form tick-I North Carolina Department of lint•ironmontal Qualify-Division of Water Resources
I' Revised 7.-27.-20I G