GW1-2022-01515_Well Construction - GW1_20220120

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: f
1.Well Contractor Information:
RANDY OWNBEY -r1�°r 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
289 ft 290 it•
3214A 4 ��
C� f` ft. ft.
�s "4i :Q11
NC Well Contractor Certification Number G „rj r'
15.FROM OUTER CTOSING for ro D MEN Reps.0 CKP(ESS a IiMATERIAL
AIR DRILLING INC o ft 53 it• 6 1O PVC
Company Name "^ 16.INNER CASING OR TUBING figeotheimal closed400
2.Wei Construction Permit#: 310235 A`'t FROM TO 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): ft ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) IIResidenlial Water Supply(single) ft. ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 it. GROUT POURED
❑Monitoring ❑Recovery ft ft.
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stonnwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control ft It.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soil/rock e, rain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
0 it 43 ft. DIRT
4.Date Well(s)Completed: 6-11-2021 well ID# 43 ft 305 ft- ROCK
5a.Well Location: ft ft
PEACHTREE RESIDENTIAL ft ft
Facility/Owner Name Facility ID#(if applicable) ft ft.
110 FAIRFAX CT,MOORESVILLE,N.C. 28117 ft ft
Physical Address,City,and Zip ft ft.
IREDELL 4624229910 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.Cer' etion•
350 30.285 N 800 56.207 W 6/11/2021
6.ls(are)the well(s): PJPermanent or ❑Temporary Signature ofCertified Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or InNo ISA 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 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: 305 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depihs i dierent(example-3@200'and 2 a 100')
25 24a. For All Wells: Original form Ito Division of Water Resources (DWR),
ff Static water level below top of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
/f rater level is shove casing,use
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
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program, 1611 MSC,Raleigh,NC 27699-1 6 1 1
13a.Yield(gpm) 30 Method of test: AIR ;
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13b.Disinfection type: HTH Amount:
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources ; Revised 6-6-2018