HomeMy WebLinkAboutWELL-09-2023-204267.tif �- WELL.CONSTRUCTION RECORD GW=1 ; Print Form :�
) For Internal Use Only:
I.Well Contractor Information:
NEILL PARDUE
1'4.WATER ZONES
AraepiitaiblafNatne FROM TO DESCRIPTION
2609A 169 rt, 170 ft;
'ft. 11.
NC Well:Contmelor Certification Number
I5:•OUTERCASING(for-ruulti=cased wells),OR LINER(if'ap livable)
AIR DRILLING INC
FROM
'TO DIAMETER THICKNESS MATERIAL
CptnpanyNantc 0 ft. 67 ft. 6 in.
PVC:
09-2023-204.267 16.INNERCASING.OR,TUBING(ecothcrmaDdosed-Ioop) ' '
2,{\'ell C ilasfrartlon Permit IV:
FROM TO . DIAMETER TRICKINESS MATERIAL _
J t,4a/I npp/Icah(e well eanchiwlion pernntc'p,e.(T/C.County,Ave,Variance,etc:) ft. ft: . in.
.3.Well Use(check well use): ff. ft.
Water Silpnle W01: .IZSCRF,RN
Dflgilcal(Ufal FROM TO DIAMETER 'SLOT SIZE THICKNESS' _ MATERIAL .1
DMunib''ipal/Ptiblic 0 fL ft. in.
'IGedtlietmal(11eating/Cooiing Supply) xDResidential Water Supply(single)
ft. ft., in.
a Industrial/Commercial DResidentialWatcrSupply(shared)
1E:GROUT t
,Irrigation FROM TO MATERIA L. ' EMPLACEMENT META IOU&AMOUNT
Non-Water:Supply Well: 0 'ft. 20 IL GROUT POURED
Ilt7oiliteriiilg Dlireeovery ft, ft.
Injection Well::
Aqr Recharge GioundwaterRemediation •fl., fr,,
ilquifcruj'te Sturagc;antl.Recove Di I9.:SAND/GRAVEL'PACIi:(if applicable) .
ry DSalintty Barrier FROM_ TO. MATERIAL. EMPLACEMENT.METItOO I
�-II Aquifer Test
t-=t DStormwater Drainage IL ft:
. . perimental Teehnolo€y DlSuhsidence Control ft. ft.
(isothermal(Closed Loop) t�•�-lI,l'racer
F_F 20..DRtLLING LOG,(attach additional sheets if,neces'sury)
(;iothermal(HentingCooling•Rettmt) 'n Other(explain under-Of Remarks) FROM fr. I TO57 ft.
DDARES('RTIPT I0N(calor,hardness,mil/matiipe:crainsbet v.. r.j
4.Date Wells)Completed:,1 0-8-24 Well rntf 57 It. 1.85 ft
ROCK
ia.Well Location: ft_ ft.
DAVID SCHULTZ ft, ft.
'Facility/Owner Name FadilityID#(if applicable) It: 'ft.
4717 ROCK BARN RD NE„CLAREMONT•N..C. 28610 fi:, ft.,
Physical\ddress;'City.and Zip (I., ft.
CATAWBA 376'301160082 ,21.REMARKS, '
County Parcel.Identification No.OM)
Sh.Latitude and longitude in•degr•ees/minutes/seconds or decimal degrees:
6N:elI field.one IatAptat is sufficient)
356 45.103 8'1° 09.110 zz• et:lion-.
10824 1
.6.•Is(a re)the'well(s) x Perlmanent .or DlTemporary SiinittureofCertifiedWellContractor Una:
liys ntnp.alet fame I he'rehy•cerir/•then the:nr/IfS)was(nvn)conrtnteted to ii.c,irdt,te.i• i
'7:..Is this a rep or tti In ezisting'tt•ell: DI`.es or DLVo tilt 1SA'(i'CAC•02C'.0160 or.I54,M':4(.'(PC•.020tI hell(:onstrw uut.S•tandarr(s,nnd tharit
I•fila r 15 ii repeti;/1ltom known ire/(extnavntcnotatt(fttrnmtu,unit expIL:,;he nofare n,the OM'tltht v,recur,f/iav'hcen prorrdet.to i/tine/1 cornea
repair under-n2k reworks.O ctibn bran the had,art/usfarm.
23.,Sitc diagriun.or additional well details: j(
It.For(eoprobc/l)1'•I'or C loscd-,Loop.Geothermal )'ells having the stone Yen stay use the back of this page to nfi''ti tdt additional.well:cite ilctails or.well
construction,only I OW-I is needed Indicate'fOTALNI14713GR•Tofwells Ctinstnrcitnn details You may also attach additional pages ifncecssat ,
drilled:
SUBMITTAL INSTRUIcTIONS. !
rf
%Total:well depth helowland.suacc: ' (ft)
Titirnudap/e ells list ail depths IIdfsrf (examph..-3@200'ardl(r71100')' 24a. For All Wells: Submit'this loon, Within�i0,days of c0'mplCtion ol'tdell
construction to the following:
111.Static water le el below top of casing:30 (ft.) Division of Water Resources',Information Processing,Unit,
if it-wit/ClL(If nbm 'easine.ose"f.,
1617 A'lail,Se.n•ic,e Center,Raleigh,NC,2.7699-1,617
11.Borehole diameter:6 (in.)
24h.Itor Injection Wells: in additnin,to sending the form to the address in 24a
12.Well etinstruction method: above,also submit one copy of this littni within 30 days:of compfelton of sell
Ti e,anger,rotuly,cable,direct push•etc.) construction Wait following:
FOR };iTGR.SUI'PL1!Z{'ELLS ONLY: Division of Water Resources,Underground Injection ControiP'rogratn,
• 1636.MailService Center,Rateihh,.NC 27690-I636
I3a.Yield(glim) 40 Method of;test6,AIR 24e.'For Water Supply& Injectiom Wells: In addition to sending the form to
.the address(e )above, also submit,one copy of this form within 3O days:Of d3b.Disinfeetitin type: HTH Amount: completion of well construction'to the county health departtnenttof the county
where constructed,
'Pone OW-1 North Carolina Departnnent:of Epvi rdnmcntnl Quality-Division of Water Resources _a2Si'
'Re�•iscd..•i.._ OfG