GW1-2022-01472_Well Construction - GW1_20220120

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
RANDY OWNBEY ���y
max" 'i14.WATER•ZONES � a, - '
Well Contractor Name 9 "' FROM TO DESCRIPTION
3214A J A�1 �, O Z�?' 409 fL 410 ft-
fL
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NC Well ComractorCertificauonNtnnber 15:[OUTER.CASING for,muld cased'wells.ORLiNER ife' licable '
ft.
AIR DRILLING INC ��\1 3�~ FROM TO DIAMETER THtCIaVESS MATERIAL
Company Name 0 fL 145 fa 6 in. PVC
237264 °'16ANNER'CASINGMR�TUBING''eotheraial cliidedd-loo �r"--gig�` `"F'
2.Well Construction Permit#: FROM I TO DIAMETER I THICKNESS I MATERIAL
List all applicable isvil construction permits(i.e.UIC,County,State,Var/ance,etc.) ft ft. in.
3.Well Use(check well use): fa fL in.
Water Supply Well: '''°17:''.SC,REEN� ' "„ h
DAgriculturat ❑MunicipaVPublic
FROM I TO I DIAMETER I SLOTSIZE THICKNESS I MATERIAL+
h. fL in.
❑Geothermal(Heating/Cooling Supply) CJResidential Water Supply(single) ft. ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) &GROUT
❑Irri ation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 _ fA GROUT POURED
❑Monitoring ❑Recovery ft. ft.
injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if eW livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 21-DRILLING LOG aftsch'additional'iheets if neceasa
❑Geothermal(Heating/Cooling Return) ❑Other("plain under#21 Remarks) I
FROM TO DESCRIPTION color,hardness soil/mck 9yM grain sin,etc
0 ft 35 fL DIRT
4.Date Well(s)Completed. 12-21-21 well ID# 35 ft 425 fL ROCK
5a.Well Location: ft. ft.
PEACHTREE RESIDENTIAL ft. m
Facility/Owner Name Facility ID#(if applicable) ft. ft.
134 BROAD BIRCH LOT#10,DAVIDSON,N.C. 28078 f. fL
Physical Address,City;and Zip ft. ft.
IREDELL 4664867544 21 REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat4ong is sufficient) 22.Certi On:
35e 30.478 N 800 47.878 w 12/21/2021
6.Is(are)the well(s): MPermanent or ❑Temporary Signature of Certified 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 PJNo ISA 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: 425 ft.
por multiple wells list all depths ifd8erent(example-3@200'and 2@100') ( ) Submit this GW-1 within 30 days of,well completion per the following:
10.Static water level below top of casing: 40 (ft.) Information
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
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12.Well construction method: 24c.For Water Su 1 and O en-Ldo Geothermal Return Wells:Copy to the
ts
(i.e.auger,rotary,cable,direct push etc.) county environmen health department of the county where insta
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells roducin ov, r 100 000 GPD:Copy to DWR,CCPCUA
12 AIR Permit Program,1611 MSC,Raleigh,NC 27699-16 1
13a.Yield(gpm) Method of test:
136.Disinfection type: HTH Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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