GW1-2022-01505_Well Construction - GW1_20220120

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: ^,
RANDY OWNBEY
14.WATER ZONES
i,!,,, FROM TO ION DESCRIPT
Well Contractor Name Y h 189 ft. 190
3214A 30 Q VA. ft ft.
fit
NC Well Contractor Certification Number ra�S1~'• 15.OUTER CASING for multi-cased wells OR LINER if a licable
AIR DRILLING INCFROM TO DIAMETER THICKNESS MATERIAL
1'S7vtt" e�1fs�,4�i J Q ft 38 ft. 6 in. PVC
Company Name
316499 16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) ft ft in.
3.Well Use(check well use): fL ft. 'in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic ft. ft in.
❑Geothermal(Heating/Cooling Supply) In Residential Water Supply(single) ft. ft
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.GRO.UT _
❑Irrigation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEM ENT METHOD&A,Iourr'
Non-Water Supply Well: 0 ft 20 ft- GROUT POURED
❑Monitoring ❑Recovery ft ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier 19.SAND/GRAVELPACK ifalicableFROM To MATERIAL! EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control ft It.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM I TO DESCRIPTION color,hardness,soil/rock type,grain sae,etc.
0 ft 28 ft• DIRT
4.Date Well(s)Completed: 8-9-2021 Well ID# 28 ft 205 ft ROCK
Sa.Well Location:
ft ft.
FRANCISCA PALAFOX ft ft
Facility/Owner Name Facility 1D#(if applicable) ft ft.
350 SEEDHOUSE RD, STATESVILLE,N.C. 28677 ft ft.
Physical Address,City,and Zip
ft ft.
IREDELL 4766153804 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.Ce ation>-
350 50.265 N 800 49.260 W
8/10/2021
6.Is(are)the well(s): InPermanent or ❑Temporary Signature ofiCertified Well Contrac r 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 l!lNo 15A NCAC 02C.0100 or 15A NCAC 02C A260 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 r21 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 1 GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also attach additional pages ifnecessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 205 (ft.) Submit this GW-I within 30 days of well'com completion the following:
For multiple wells list all depths if dierem(example-3@200'and 2@100') y p per g'
10.Static water level below top of casing: 30 (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
i
11.Borehole diameter: 6 (in,) 24b.For IDjection 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,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 1400,000 GPD:Copy to DWR,CCPCUA
40 AIR Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test- !`
13b.Disinfection type: HTH Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources III Revised 6-6-2018