GW1-2022-01477_Well Construction - GW1_20220120

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
RANDY OWNBEY
-ra •'x4:.'4 i1114NES-';: -�
Well Contractor Name ry FROM TO DESCR�TION
ft ft.
3214A �r�,� 28s 2s0
fL ft,
NC Well Contractor Certification Number V
J� 18,'OUTER OA511VG.''for d ptaeQ rdc9[$.O i 11V>�[t 1f 1lcabte .
AIR DRILLING INC FROM TO DIAMETER ; THICKNESS MATERIAL
0 fL 152 ft• 6 '" GALV
Company Name
at ivi 1t: Asllvca TlT10M' elosed: ., __ y,.«
2.well Construction Permit#: 309745 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,variance,etc.) ft• ft 1n.
3.Well Use(check well use): ft ft. in.
Water Supply Well: FROM To I DIAMETER I SLOT SIZE THICKNESS MATERIAL~
❑Agricultural ❑Municipal/Public IL IL in-
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) f, ft in
❑Industrial/Commercial ❑Residential Water Supply(shared) lR ROUT-
DIrri ation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Wtiter Supply Well: 0 ft• 20 ft GROUT POURED
❑Monitoring ❑Recovery ft. ft
Injection Well: & ft
❑Aquifer Recharge ❑Groundwater Remediation
19:.SAN0krsMVEL-,PAC1Crfa ble; '
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO MATERIAL EMPLACEMENTMUMOD
❑Aquifer Test ❑Stormwater Drainage % ft
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) OTracer :20.DRi1 LiI�GTtt)G.isttiacti:ad&thnr6alabee if.'." {:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIP77oN trolor h eauroek o ' eta
0 fc 142 ft DIRT
4.Date Well(s)Completed: 4-12-2021 Well ID# 142 ft- 305 IL ROCK
ft. ft.
5a.Well Location:
BARTON BUILDING ft ft.
Facility/Owner Name Facility ID#(ifapplicable) ft ft
126 REDBUD LANE,MOORESVILLE,N.C. 28117 & ft.
Physical Address,City,and Zip ft' ft
IREDELL 4629704988 an ReiblARlcS. . r: .
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 'eeetio
350 38.011 -- N 800 55.351 w 4/12/2021
6.Is(are)the well(s): Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or [nNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If 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•iorm.
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 Ovee in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 305 (fti) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if dierent(example-3 a200'and 2@100')
60 249. 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.
If water level is above casing,use"+"
I1.Borehole diameter: 6 (i®•) 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,eta) county enVirorunental health department'o a county where in
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 1100,000 GPD:Copy to DWR,CCPCUA
139.Yield(gp®) 20 Method of test: AIR
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: g
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018