GW1-2022-01498_Well Construction - GW1_20220120

i
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: j
1.Well Contractor Information: I
RANDY OWNBEY 14.WATER ZONES,
Well Contractor Name FROM TO DESCRIPTION
Q?.t. 629 ft- 630 fL
3214A 2 © � fL It. I
NC Well Contractor Certification Number r r r7
J. 15.OUTER CASING fo-r multicased''wells OR LINER if a licable
AIR DRILLING INC �^ { , y� `rate FROM TO DIAMETER THICKNESS MATERIAL
„•- �,, 0 fL 42 ft 6 i in. PVC
Company Name
236368 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. fL in.
3.Well Use(check well use): fL ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public fL ft. in.
❑Geothermal(Heating/Cooling Supply) MResidential Water Supply(single) ft. ft.
❑IndustriaUCommercial ❑Residential Water Supply(shared) 18.GROUT
DIrri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 20 fL GROUT] POURED
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
DAqui£er Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage fL ft.
❑Experimental Technology ❑Subsidence Control fL ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock a rain size,etc.
0 ft- 32 ft. DIRT
4.Date Well(s)Completed: 9-24-2021 Well ID# 32 fL 645 fL ROCK
5a.Well Location: fL It.
PEACHTREE RESIDENTIAL fL fL
Facility/Owner Name Facility ID#(if applicable) ft fL
106 COPPER PINE LANE,DAVIDSON,N.C. 28036 fL ft.
Physical Address,City,and Zip
ft. ft.
IREDELL 4664862928 21.RENIARKS
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 Catio
350 30.515 N 800 47.122 W
9/24/2021
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing thisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 01C.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 i GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).Youlmay also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 645 (ft)
For multiple wells list all depths ifdrr erent(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: 50 (ft) 24a. 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
6 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
i '
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
i
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over:100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 20 Method of test- AIR Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
13b.Disinfection type: HTH Amount:
i
C
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
r
I
i