GW1-2022-01469_Well Construction - GW1_20220120

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WELL CONSTRUCTION RECORD(GW-1) .� For Internal Use Only:
1.Well Contractor Information:
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RANDY OWNBEY `_ ,'�c
�r"^� ��' �. 14.WATER ZONES
Well Contractor Name ' �"✓' � :{��� , FROM TO DESCRIPTION
3214A 269 ft 270 ft
ft. ft-
NC Well Contractor Certification Number �' > :d 15.OUTER CASING for multi cased wells OIL
if a livable
AIR DRILLING INC =`>r' FROM TO DIAMETERI THICKNESS MATERIAL
,;. ;,�
0 ft. 55 ft. 6 !in. PVC
Company Name i
16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: 313597 N FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.U1C,County,State, Variance,etc.) ft ft in.
3.Well Use(check well use): ft ft. !in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER �SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft in.
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wel Is>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft- GROUT POURED
❑Monitoring ❑Recovery ft ft
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL: EMPLACEMENT NIETHOD
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness,soiUrock e, n sae,etc.
0 ft 45 ft DIRT
4.Date Well(s)Completed. 6-8-2021 Well ID# 45 It- 285 ft- ROCK
Sa.Well Location: ft. ft.
PRINCETON HOMES ft. ft
Facility/Owner Name Facility[D#(if applicable)
ft ft.
540 KENWAY LOOP,MOORESVILLEXC. 28117 ft It.
Physical Address,City,and Zip ft. ft.
IREDELL 4638294033 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one]at/long is sufficient) 22.C ' reatio
350 37.424 N 800 54.347 w 6/8/2021
6.Blare)the well(s): InPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or It No 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;t'21 remarks section or on the hack 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-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: 285 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if clierem(example-3@200'and 2@100')
50 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft) Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
lfwater level is above casing,use
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 overt 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield m 15 Method of test- AIR Permit Program, 1611 MSC,Raleigh,NC 27699-1 6 1 1
(gp ) II(
13b.Disinfection type: HTH Amount:
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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