GW1-2022-01496_Well Construction - GW1_20220120

WELL CONSTRUCTION RECORD fG*111. For Internal Use Only:
1.Well Contractor Information:
RANDY OWNBEY PFROM
ATER ZONES
Well Contractor Name To DESCRIPTION
3214A �� Q .L ft. 190ft•NC WellContractorCertificationNumberfL ft.
15.OUTER CASING for multi-cased Wells)OR LINER if a licable
AIR DRILLING INC "'`"' °`
1.�j._,,ji;r--•1wt ,d-, FROM TO DIAMETER THICKNESS MATERIAL
j�, 0 ft. g8 ft. in. PVC
Company Name
318023 16.INNER CASING OR TUBING eothermal closed400
2.Well Construction Permit#: FROM I TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) fL I ft. in.
3.Well Use(check well use): :779
ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ClResidential Water Supply(single) ft. ft. in.
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD, FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 IL 20 ft. GROUT ' POURED
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK ifa licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control tL ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessar
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,solUhock type,grain size,etc.
0 rL 28 rt. DIRT
4.Date Well(s)Completed: 9-17-2021 Well ID# 28 fL 205 ft. ROCK
Sa.Well Location:
ft. ft.
MARY GOCHNAUER ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
950 ELMWOOD RD,STATESVILLE,N.C. 28677 ft. ft.
Physical Address,City,and Zip ft. ft.
IREDELL 4783052641 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Cc rcatio
por
350 45.328 N 800 45.844 W 9/17/2021
6.Is(are)the well(s): Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,1 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.0/00 or ISA NCAC 02C 0200 Well Construction Standards and that a copy
/'this is a repair,fill out known well construction information and explain the nature of ilhe of this record has been provided to the well owner.
repair under 421 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-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: 205 (ft
/br undtiple wells/isra//depths t/di�erem(eromple-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: 20 (f`) 249. 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 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 m tailed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
25 AIR Permit Program,1611 MSC,Raleigh,iNC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: HTH Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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