GW1-2022-01518_Well Construction - GW1_20220120

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WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
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1.Well Contractor Information:
RANDY OWNBEY 14.WATER ZONES
Well Contractor Name p�' FROM TO DESCRIPTION
2Q� 329 ft 330 ft
3214A ,A�f �+ r i?Zii, ft. ft j
NC Well Contractor Certification Number r rnt Ott t
"s 15.OUTER CASING for multi-cased wells OR LINER if a (cable
AIR DRILLING INC jt;':3''` �gn; (9i1 FROM TO DIAMETER THICKNESS MATERIAL
tit,.:�:•�• 0 ft- 141 ft. 6 in. I GALV
Company Name
316346 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#• FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,Slate, 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. in.
❑Geothermal(Heating/Cooling Supply) In Residential Water Supply(single) ft ft in.
❑Ind ustrial/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 ft GROUT POURED
❑Monitoring ❑Recovery ft ft.
Injection Well: 4t 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 ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional"sheets if necessary)
❑Geothermal FROM TO DESCRIPTION color,hardness,soillrock e, rain size,etc.
(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
0 ft 131 ft- DIRT
4.Date Well(s)Completed: 6-23-2021 Well ID# 131 ft• 345 ft ROCK
Sa.Well Location:
ft ft.
SOUTHERN COTTAGE ft fL
Facility/Owner Name Facility ID#(if applicable) ft ft.
521 MIDWAY LAKE RD, MOORESVILLE,N.C. 28117 ft ft.
Physical Address,City,and Zip ft. ft.
IREDELL 4654391359 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.Certifi
350 31.139 N 800 50.164 W
6/23/2021
6.Is(are)the well(s): MPermaneut or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,/hereby certify that themell(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 01C.0200 Well Construction Standards and that a copy
/fthis is a repair,fill out known well construction information and explain the nature of the of this record has beenprovided 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-Lop 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 if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS'
9.Total well depth below land surface: 345 (ft) Submit this GW-1 within 30 days of well completion the following:
For multiple wells list all depths if dierent(example-3@200'and 1@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),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1 6 1 7
lfwater level 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
12.Well construction method: 24c.For Water Supply and Open-Lo p;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) 30 Method of test: AIR Permit Program,1611 MSC,Raleigh,NC 27699-1611
136.Disinfection type: HTH Amount: k
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources i Revised 6-6-2018
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