GW1-2022-01471_Well Construction - GW1_20220120

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WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only:
1.Well Contractor Information: ,. FTO
RANDY OWNBEY La
14t,WATER ZONES
Well Contractor Name FROM To DESCRIPTION
3214A A�'+ �+ 2� 149 fL 150 ft.
NC Well Contractor Certification Number i�t^ fL
ft.
AIR DRILLING INC ��sr `4 '`"lf• Or 15rOUTER.CASING form6ldcruedrwdllafORiIINER'!fe'llesble
Cr�i j FROM I DIAMETER THICKNESS I MATERIAL
Company Name 0 IL 77 ft 6 in• PVC
AP-314549 i44k 4NNER`CASING OR TUBING cotherioal elused-loo
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,eta) ft fL in.
3.Well Use(check well use): ft. ft. im
Water Supply Well: 117.-:SCREEN*, a®J
❑A Cultural FROM TO DIAMETER SLOT SIZE THICKNESS�'y MATERIAL
Bn ❑Municipal/Public tL fL in
❑Geothermal(Heating/Cooling Supply) MResidential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) ft. fL in.
4&GROUT
❑Irri ation ❑Wells>100000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
'
Non-Water Supply Well; 0 fL 20 fL GROUT POURED
❑Monitoring ❑Recovery fL ft.
Injection Well:
❑A uifer Recharge ❑G roundwater Remediation ft. fL
❑Aquifer Storage and Recovery ❑Salinity Barrier 79 SAND/GRAVEL PACK ifa licable'
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage fL &
❑Experimental Technology ❑Subsidence Control M fL
❑Geothermal(Closed Loop) ❑Tracer 20:-DRILLING.LOG attach additional'sheets if fiecessarylr
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks FROM TO DESCRIPTION color hardness soiUroeE n size,etc
0 fa 66 tr• DIRT
4.Date Well(s)Completed: 12-16-2021 Well ID# 66 fL 165 fL ROCK
5a.Well Location: fL ft.
JASON STEELE fL fL
Facility/Owner Name Facility ID#(if applicable) R fL
1316 TABOR RD,HARMONY, N.C. 28634 iL iL
Physical Address,City,and Zip ft. fL
IREDELL 4861481155 21REMARKS
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.Ce on:
35° 59.469 N 80° 48.419 W
12/21/2021
6.Is(are)the well(s): MPermanent or ❑Temporary Signature ofCdffified Well Contractor Date
By signing this form,I hereby cert fy that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC O2C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
/fthis 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 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: 165
(ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths tfdfferenr(example-3@200'and 1Q/00')
10.Static water level below top of casing: 40 (fL) 249. For All Wells: Original form Ito Division of Water Resources (DAIR),
lfwater level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:(i.e.auger,rotary,cable,direct push etc.) 24c.For Water Supply and O en-LoI "Geothermal Return Wells:Copy to the
county environmental health department ot 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) 10 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