GW1-2022-01517_Well Construction - GW1_20220120

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor information:
RANDY OWNBEY '`'n
n 14.WATER ZONES
Well Contractor Name
FROM TO DESCRIPTION
3214A 4� ©�C ff, 349 ft- 350 ft.
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING for mulfi�ased wells OR LINER if a licable
AIR DRILLING INC ��� FROM TO DIAMETERI THICKNESS MATERIAL
``^: ' 0 ft 955 ft. 6 in.
' PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 245792 \,.' FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U/C,Coun(y,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft.
❑Geothermal(Heating/Cooling Supply) EnResidential Water Supply(single) ft. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl atlon ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 It. 20 ft• GROUT POURED
❑Monitoring ❑Recovery ft. fL
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 ❑Stormwater Drainage ft. ft.
❑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,soit/rock type,grain sae,etc.
0 It- 85 ft. DIRT
4.Date Well(s)Completed: 5-17-2021 Well ID# 85 It. 365 ft. ROCK
5a.Well Location: ft fr.
LAKEMIST HOMES fr ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
113 HIDDEN MEADOWS,MOORESVILLE,N.C. 28117 ft. ft.
Physical Address,City,and Zip ft. ft.
IREDELL 4649023581 21•REMARKS
County Parcel Identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Iat/Iong is sufficient) 22.Cer On'
35a 38.164 N 800 53.037 W
5/17/2021
6.Is(are)the well(s): OPermanent 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 IlNo I5A NCAC.02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
lfthis 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: 365 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdierent(example-3@200'and 2@100')
50 24a. For All Wells: Original form to Division of Water Resources (DWR),
if Stalk water level below top of casing: (ft) Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
ljwolerlevel is above 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
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
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) 8 Method of test: AIR
Permit Program,1611 MSC,Raleigh,NC 27699-161 1
13b.Disinfection type: HTH Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018