GW1--00719_Well Construction - GW1_20240119

WELL CONSTRUCTION RECORD (GW-1) l
]�or inlornal Use Only:
I.Well Contractor information:
CHAD HARTNESS , ,
Well Contractor Name 14,WATER ZONES 1 I
mom TO DISCRII'rioN
2901A 389 11. 390 1•I• , i -- ___
\('Well Contractor Certification Number ft. fl, -- ---- — ___
i I---
A I R DRILLING I N C 15.OUTER CASING(for multi-cased,yells)OR LINER(If applicable)
PROM TO DIAmt:TER' _I'IIICKNEOS mit•r iumt___
Company Name 0 ft. 82 ft. 6 T,—{lu' PVC
IS.INNER CASING OR TUBING(geothermal closed-loop)2.Well Construction Permit l/: 32 Muni: ' TO DIAuj E't$:R THICKNESS MATERIAL --List all opplic•ah/c'well construction permits(i.e.(1/C.',County,Slats, Variance,me.) fL ft. I' in. — "'
3.Well Use(check well use): ft, ft, in,
Water Supply Well: • 17,SCREEN
•
lJr\gricultural , tttOJt ' ToDIAL-t:TE.R_ SLOTSI'/.E THICKNESS .\IATERb\L
❑Municipal/I oboe ft. ft. in,',
❑Geothermal(Heating/Cooling Supply) CJResidential Water Supply(single) _..
fL ft. in,'
['Industrial/Commercial IOResidential Water Supply(shared)
IS.GRouT
illlrrigalioit ❑Wells> 100,000 GPD ruo�t TO MATERIAL EM1'I.ACtttutOtT MI•.'rttoD.C.:AMUt.NT
Non-Wafer Supply Well: 0 II' 20 fl' GROUT POURED
CiMonitoring ❑Recovery fl. ft. __�__-----
Injection Well: --
lAquitcr Recharge IJGroundwatcr ltctnodialion ft. ft. -- ---- —
\yuilcr Storaec and Recovery19.SAND/GRAVEL PACK(if applicable)
LlSttlinityBarrier Ittto.t _ro MATERIAL.. EmPLLAQ:istrtTanrnt)to
i IAcluifer'lest LlStormwa ter Drainage ft. Ft. —
llixperintental'fechnolo t __ -=——-------------•----
b) EISubsidencc Control ft. ft.
1:1Geolhcrmal(Closed Loop) 13Tracer 20.DRILLING LOG(attach additional'sheets if necessary)
❑Geothermal(Healing/Cooling Realm) ❑Other(explain under R-21 Remarks) I'I•
WM ro DESCRIPTION(color,bnrrhtcss_snil/rock t qsc gndn size,cw.) ..
U ft. 72 fl. DIRT 1
4.Date Well(s)Completed: 1-9-2023 Well iD// 72 fl' 405 f1. ROCK i ' — v
5a.Well Location: ft. ft.
SPIVEY CONSTRUCTION ft, ft --"
a .t,.Facility/Owner Name Facility iDN(il':tpplicnble) ft. R. - 9 L L.tk„*i..y.; ; r,t
171 FLOWER HOUSE LOOP, TROUTMAN,N.C. 28166 ft. ft. '"�?'
Physical Address.City,and Zip ft. ft. I' �U�4
IREDELL 4740759725 21,REMARKS t . tut. (:;:?
.its rr.,...,.,:
County . Parcel Identification No.(PIN) I. CJY�Cy' OG
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: /�Orwell Ile'''.licld,unc tut/loot;is sul'IicicnQ �2.Cain tton: :211�
35° 40.481 N 80° 51 .588 ' `�
1° 1/9/2023
O. Is(are)the well(s): I"IPer'nt:utent or f_l'l'emporar) Signature ofC'cr,ilied Well Contractor Date —
11y.rignihj this.tin-si,/hereby rent//i•Mal the irel/(r)ntt.v(n•cre,consrrttc led in oroar/mtrr n id,
7.Is This:I repair to an existing well: CIVes or IfiNo I.t.t tVC.'IC'02C.0/00 or/S4 NC:IC 02C.0200 II•c•//Cou.viuiirtian Siondrrrr/.r ant/rho,a ru/n
I/This is o repair,jilt oat known well c•onsa-uc'tiort inlbrnraliott and explain the nature o/'the iJ'this record has been provided r)flu'well owner.
repair under Ii?i remarks section or on the had;()Phis Arm.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction inli�
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
(add'Sec Over'in Remarks Box).You may attach additional pages if
construction,only 1 OW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
24.SUBMITTAL INSTRUCTIONS I.
9.'I'otal well depth below land surface: 405
I'armultiple wells list all depths ifdi(/i•r'ent(etrnip/e-3 11200'and 2@)/Oft') (ft.) Submit this CW-1 within 30 days of well completion per the following:
10.Static touter level below top of casing: 40 rt 24a. For All Wells: Original form 1, Division of Water Resources (DWR),
!/'water level is«have rasing,use"-I" ( ) Information Processing Unit, 1617 MSG,Raleigh,NC 27699-I G 17
11,Borehole diameter: 6 (in.) 24b.For Injection Wells: Copy to DWR, Underground Injection Control (ICC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department;oCthe county where'installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing overl(I00,000 GPO: Copy to DWR,CCI'C'UA
13a.Yield(gpm) 5 Method of test: AIR Penult Program, 161 I MSC,Raleigh,NC 27699-1611
I3b.Disinfection type: HTH Amount:
furw OW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-0-2(1I S
j 1 .