GW1--00737_Well Construction - GW1_20240119

WELL CONSTRUCTION RECORD GVy-1 I Print Form
For tote:mai Use Only: ,T-
I.Well Contractor Information:
CHAD HARTNESS I
14.WATER ZONES
Well Contractor Name PROM
.
2901A 340 ft.
-- 350 ft. I
NC Well Contractor Certification Number ft• ft -1 — -`--`- -- - - ...
AIR DRILLING INC IS.ouTER CASING(for multi-cased wells)OR LINER(if op tlicable)
moll ro h1SI69IYR I •11mCt.Nt,1 MATERIAL
RIAt.
Company Name 0 IL13U f6 U in• 1
2023-26861
r h�° 1
2.Well Construction Permit i/: Iti.INNER CASING OR TUBING(geothermal dosed-loop) -` __IrpmTo_ ui,��urn•at rnua:�i•:Ss �I,�n:ItII.`—
List all applienhle,cell raustrurtiot permits(i.e. WC,,Comity,State, Pariance•car•:) ft. f t. i
_ , -`
- s ---. -____ 1
3.Well Use(cheek well use): ft.
ft. , in.
Water Supply Well:
17.SCREEN
Agricultural NIt(»I TO _ul it�rPl__It_A SlOtSt%F' -n I^ rCI<NttSs CI A rI{RI.t I.
Municipal/Public - ft. ft. in.; - --_
Geothermal(f loafing/Cooling Supply) XDResidential Water Supply(single) _--
lndusuial/Conunorcjal ft. ft. in•' _._ ._._---
Q Residential Water Supply(shared) '
Irrigation I i.GROUT —
I'Itoirl _`fo dL\_I'IsliL51• IiBllnt�l?i�tl:\'I' lli'I'IIOU\.\,11(!ll\'I'
Non-Water Supply\fell: - -. _----
MonitoringD c Itou'r' Poultt o
Injection Well: Recovery
ft. fh
Aquifer Recharge �Croundwalct'Remc(lialion ft ft. -- _
Aquifer Storage mad Recovery E Sal nuty DaI•I er
IS.SAND/GRAVEL PACK(if applicable)
1,Itorl - TO _NI/NTI_:RIA I. EN!P I,ACENIENT Si t:rn Uhl
Aquifer Test ❑IStormwaler Drainage ft. ft. _
Experimental Technology ❑ISubsidence Control - •
----:-- -- - -
rt. ft.
•Geothermal(Closed Loop) Qi'l'racer
20.DRILLING LOG(attach nl(lition»I shells if necessary)
Geothermal(Beating/Cooling Return) riOther(explain under 1/21 Remarks) t•Ro;tt •ro urscuu"rum tenon bnrancss,se0nc�k n,e,;;
)_..,uu size,etc,)
ft. 17.a ft. Dllfl' ._ _ .
4.Ilate 11'ell(s)Completed: 7 10-23 Well1Dl/ ______— ---`-- - __._____,--------------.. .
12.0 11, 365 It' ROCK
ft. ft.
5a.Well Location:
DEAN GOO D I N rt——_ ft.---—___-_...-------{- k 4 _,)
Facility/Owner Name Facility 1D11(if applicable) `--t't. ft.
430 N CHIPLEY FORD RD,STATESVILLE,N.C, 28677 —rt. ft. —_.---•---_—�__JAN-2--r3---2024 - --'
Physical Address.City,and Zip rt. ft. -- _
IREDELL 4739298108 21.REMARKS 1,-eC'.:e;1 Oci
,:tts
County Parcel Identification No.(PIN)'.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -
—-- I
(if well field,one Im'lutt is sufficient) -2,'(',P line)�On: -_- ----
35° 55.510 I N 80° 54.591 _,. _ ...•
NV
' •-10-23
6.Is(nre)the wells) X(Permanent or ❑I.1'ctnl)otary Signature of Certified Well Contractor ''r I),Ic
rye'' By signing This firm, i/her'('/,r errli/i'that the ire/i(s) was Greco•)c nistrnag,in accordance
7.is this a repair to an existing well: 0Yes or ONo with IS.•t NCAC 02C:0100 or/2,1 NC',IC:(/2C'.0200(Weil Consu•uc•Nun Stuttdurr/S and that a
If this is a repair,fill scot knolls,,cell coons-adlion in/iu•nrn io,t and explain the nature of the copy of this record has been provided to(he'irell ounce.
repair under 1121 remarks section or on the back gratis Arm.
23.Site diagram or additional well details:
S.For Gcoprobe/DPT or Closed-Loop Geothermal Wells having the same You (nay use the back of this page to;provide additional well site details or well
construction,only I (2W-I is needed. hidicute'l Ol'AI.NUMBER of wells construction details. You may also attach additional pages it necessary.
drilled:_-__ __ Pe g
SUBMITTAL INSTRUCTIONS '
9.Total well depth below land surface: 365
(ft.)
For multiple,rr/ls list all depth,siJ'diJi'nratt(example-.i(rh20(1'mu!2@100') 2I:t, Iror All Wells: Submit this form within 3U days of completion of well
constuction:to the following:
50
i
10.Static Mato level below top of casing: I,
If wnteric •
lev s a em.easing,tine M.) Division of Water Resources,Information Processing h itit,
1617 Mail Service Center,.Raleigh,NC 27699-I617
•
11.13m'eldc(li:uuclo: 6 enti
(in.) 24h. For Injection Wells: In addition;to sending the lin•nt to the address in 2ela
12.Well construction method: above, also submit one copy of this forth within :30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following: ,
Division of Water Resources,Undlrgrouu(1 Injection Control Program,
WATER SUPPLY WELLS ONLY:
1636 Mail Service Center,(Raleigh,NC 27699-1636
13a.Yield(gpm) 9 Method of test: AIR 24c. For Water Supply& Inlection Wells: In addition to sending the form to
the address(cs) above, also submit otje copy of this limn within 30 days of
13 b.Disinfection type: HTH Amount: completion of well construction to the county health department of the county
where constructed.
Form OW-I North Carolina Department orlinviroumental Quality-Division of Water Resources I
Ii Revised:!-.'. -h1 I u