GW1-2022-01509_Well Construction - GW1_20220120

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: s
RANDY OWNBEY WATER ZONES j
FROM TO DESCRIPTION -.
Well Contractor Name O^r1 229 ft 230 ft. I
3214A �, t l �� ft. ft.
NC Well Contractor Certification Number r�ctg�(1�V IS.OUTER CASING for multi-cased wells OR LINER if a licable
AIR DRILLING INC ,3\t� t,aJ4v;A0% FROM TO DIAMETER THICKNESS MATERIAL
rrr 0 ft 42 ft. 6 in. PVC
Company Name
16.INNER CASING OR TUBING eotherm&I closed-loop)
2.Well Construction Permit#: AP-311634 FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) fk ft. in.
3.Well Use(check well use): fk ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) In Residential Water Supply(single) ft. ft. in.
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Uri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fk 20 fr- GROUT POURED
❑Monitoring ❑Recovery ft. ft.
Injection Well: fk ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage fk fL
❑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#21 Remarks) FROM TO DESCRIPTION color,hardness,miVroek a 'n sae,etc
0 ft- 32 ft- DIRT
4.Date Well(s)Completed: 7-23-2021 Well iD# 32 fk 245 ft' ROCK
5a.Well Location: ft. fr.
CORNERSTONE III PROPERTIES ft. ft.
Facility/Owner Name Facility tD#(if applicable) fk fk
132 TALLEY RIDGE RD, TROUTMAN,N.C. 28166 ft ft.
Physical Address,City,and Zip ft. ft.
IREDELL 4731223528 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.Ce lion:
350 41.339 N 800 54.347 W 7/23/2021
6.Is(are)the well(s): In Permanent or ❑Temporary Signature o£Certified Well Contractor Date
By signing this form,!hereby certify that the ivell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or In No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 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 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 1 GWA 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: 245 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if diereni(example-3@200'and 2 r�100') y p
10.Static water level below top of casing: 50 (ft.) Information
For All Wells: Original form !to Division of Water Resources (DWR),
ljwater 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
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
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield m 15 Method of test- AIR Permit Program, 1611 MSC,Raleigh,NC 27699-1611
(gP ) �.
13b.Disinfection type: HTH Amount:
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Form G W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018