GW1-2022-01483_Well Construction - GW1_20220120

1
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
i
RANDY OWNBEY •^'
14.WATER ZONES
d s f
Well Contractor Name FROM TO DESCRIPTION
^.y
3214A n 389 ft- 390 ft.
24?t• ft. ft.
NC Well Contractor Certification Number „,�� © ti;�lt 15:OUTER CASING for mulfi cased ells OR LINER if a licable '
AIR DRILLING INC ;� srr +� FROM TO DIAMETER THICKNESS MATERIAL
Company Name •5, �` 117 b Q ft 47 ft- 6 in. PVC
v 16.INNER CASING OR TUBING eothermal closed-loon)'
2.Well Construction Permit#: FROM TO I DIAMETER F THICKNESS I MATERIAL
Usv all applicable well construction permits(i.e.(11C,County,State, Variance,etc) ft. ft. in.
3.Well Use(check well use): 1L ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
InIrrt ation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. GROUT POURED
❑Monitoring ❑Recovery 1L ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL I EMPLACEMENTMETHOD
OAquiferTest ❑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 421 Remarks) FROM To DESCRIPTION color,hardness,soil/mck type,grain size,etc.)
0 It- 37 ft. DIRT
4.Date Well(s)Completed: 10-19-2021 well ID# 37 fL 405 ft. ROCK
Sa.Well Location:
ft. ft.
WOODLEAF PROPERTY OWNERS ASSOC ft ft.
i
Facility/Owner Name Facility ID#(if applicable) 1L tt.
CORNER OF FERN HILL&KENWAY,MOORESVILLE,N.C.28117 fL ft.
Physical Address,City,and Zip ft. ft.
IREDELL 21.REMARKS
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.CofiCB
350 38.275 N 800 54.231 W - 10/19/2021
6.Is(are)the well(s): InPermanent or OTemporary 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 nNo 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a copy
lfthin is a repair,fi//out known we/1 construction it formation and explain the nature of the of this record has been provided to the wet/owner.
repair under 1121 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: 405 (ft)
For multiple wells list al/depihs ifdijferent(example-3 t@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.) 249. For All Wells: Original form:to Division of Water Resources (DWR),
lfwater level is above casing,use"+" Information Processing Unit,1617 MS'C,Raleigh,NC 27699-1617
I I.Borehole diameter: 6 (in.) 24b.For Injection Wells:Copy to DWR, Underground Injection Control(IUC)
Program,1636MSC,Raleigh,NC 27699-1636
r ,
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
Permit Program,1611 MSC,Raleigh,
13a.Yield(gpm) 10 Method of test: AIR NC 27699-1611t
13b.Disinfection type: HTH Amount:
I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018