GW1-2022-01449_Well Construction - GW1_20220120

WELL CONSTRUCTION RECORD(GW-1), � For Internal Use Only:
1.Well Contractor Information:
RANDY OWENBY WATER ZONES .
Well Contractor Name � � © r a••>5 FROM TO DESCRIPTION
3214A r' 449 ft 450 ft
' cr�� ft. ft
NC Well Contractor Certification Number c ` j�
15.OUTER CASING for mulfi cased wells OR LINER if a `livable
AIR DRILLING, INC 4 k FROM TO DIAMETER THICKNESS MATERIAL
0 it gg ft. 6 in. PVC
Company Name
08-2019-1 ZO66 16.INNER CASING OR TUBING eothermal closed-too
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft ft in.
3.Well Use(check well use): ft• ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public fa ft. in.
❑Geothermal(Heating/Cooling Supply) MResidential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18 GROUT
❑II7t ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 IL 20 It- GROUT POURED
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft.❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK-if a livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft• ft.
❑Experimental Technology ❑Subsidence Control ft I,
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary).
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock e,grain size etc
0 ft 78 1" DIRT
4.Date Well(s)Completed: 1-15-2021 well ID# 78 ft 465 ft- ROCK
5a.Well Location: ft. ft.
DENALI BUILDERS ft. R.
Facility/Owner Name Facility ID#(if applicable) ft ft.
1404 RON WHICKER DR, CATAWBA, N.C. 28609 ft ft
Physical Address,City,and Zip ft ft
CATAWBA 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Cc eatio
350 40.309 N 800 59.102 W 1/15/2021
6.Is(are)the well(s): nPermanent or ❑Temporary Signature ofCertified Well Contractor Date
By signing this form,/hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
1f this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 465 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100')
10.Static water level below top of casing: 60 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+„ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
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 of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 12 Method of test AIR Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018