GW1-2022-01484_Well Construction - GW1_20220120

WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information:
RANDY OWNBEY p
f— t 7 r t� 14.WATER ZONES'
Well Contractor Name J _'� to FROM TO DESCRIPTION
3214A Nelh . 32s ft- 330 ft. I.
I NC Well Contractor Certification Number AID 2 0 20?2 fL ft.
o ,^I Ini9. OINNNER
CASING for multi-cased wells OR LINER if applicable)
AIR DRILLING INC �����:;a ° `I TO DIAMETER THICKNESS MATERIAL
t s t
28 ft. 8 in.
Company Name `1 ! v� PVC
ASING OR TUBING eothermalclosed-loo2.Well Construction Permit#: TO DIAMETER THICKNESS MATERIAList all applicable well construction permits(i.e.U1C,County,State, Variance,etc.) ft. in.
3.Well Use(check well use): fL ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE I Tt11CKNESS IMATERIAL❑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
InIrrl ation ❑Wells>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:
❑A uifer Recharge ft. ft.
9 g ❑Groundwater Remediation
uifer Storage and Recovery 19.SAND/GRAVEL PACK ifa licable
❑A
9 g ry ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTM1fETHOD
OAquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. R.
OGeothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necesse
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/mck type,Rnin size,etc.
0 ft 18 ft- DIRT
4.Date Wcll(s)Completed: 10-20-2021 well ID# 18 fL 345 ft. ROCK
5a.Well Location: ft. it.
DARRELL WATTS ft ft.
Facility/Owner Name Facility ID#(ifapplicable) M ft.
320 CELESTE EUFOLA RD,STATESVILLE,N.C. 28677 —ft —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.Cc ation•
350 44.366 N 80e 58.554 W
10/20/2021
6.Is(are)the well(s): ClPermanent or ❑Temporary Signature of ertified Well Contractor Date
By signing dtisforni,l hereby certIfy that the well(t)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair•fill out known sve11 construction information and explain the nature of the of this record has keen provided to the welPou•ner.
repair under 1121 remorks section or on the hack of this fornn.
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: 345 ft.)
For multiple wells list all depths ifdijferent(example- a 3 00'and 2 r(�i 100') ( Submit this GW-I within 30 days of well completion per the following:
10.Static water level below top of casing: 25 (ft.) Information
For All Wells: Original form to Division of Water Resources (DWR),
/f water level is above caring,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
i..Well construction method: 24c.For Water Supply and Open-Loon 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 producine over.100 000 GPD• Copy to DWR,CCPCUA
139.Yield(gpm) 25 Method of test AIR Permit Program, 1611 MSC,Raleigh,NC 27699-1 6 1 1
13b.Disinfection type: HTH Amount:
f
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources i Revised 6-6-2018