GW1-2022-01468_Well Construction - GW1_20220120

WELL CONSTRUCTION RECORD GW-19'yJ For Internal Use Only:
1.Well Contractor Information: , '
NEILL PARDUE i��� VV
ZN 14.WATERZONES
Well Contractor Name
�,�7� �` t^'m 1 FROM TO DESCRIPTION
� DESCRIPTION
2609A � \ ry r 269 ft 270 ft
Cs ft ft.
_try
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
AIR DRILLING INC v FROM TO DIAMETER THICKNESS MATERIAL
0 ft 73 ft. 6 in. PVC
Company Name
313596 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER I 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.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) In Residential Water Supply(single) ft. ft in.
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 rt• GROUT POURED
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(ifavolicable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft ft
❑Experimental Technology ❑Subsidence Control ft. ft.
❑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,soiurock type,grain size,etc.
0 fL 63 rL DIRT
4.Date Well(s)Completed: 6-4-2021 Well ID# 63 l" 285 ft- ROCK
5a.Well Location: ft. ft.
PRINCETON HOMES LLC ft ft
Facility/Owner Name Facility ID#(if applicable) ft ft.
534 KENWAY LOOP,MOORESVILLE,N.C. 28117 IL ft
Physical Address,City,and Zip ft ft.
IREDELL 4638293194 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat(long is sufficient) 22.Certifi o
350 37.430 N 800 54.359 W 6/4/2021
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or InNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
/f 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 I GW-I 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: 285 (ft)Tormultiple wells listall depths ifdiereni(example-3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
�50 249. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (f4) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
f water level is above casing,use"-"
11.Borehole diameter: 6 (in.) 24b. For Infection Wells: Copy to DWI, 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 m 12 Method of test: AIR Permit Program, 1611 MSC,Raleigh,NC 27699-1611
(SP ) i
13b.Disinfection type: HTH Amount: i
i
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources i Revised 6-6-2018
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