GW1-2022-01520_Well Construction - GW1_20220120

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information: �m �
RANDY OWNBEY 7�'�"�� �s 14.WATER ZONES'
fAy FROM TO DESCRIPTION
Well Contractor Name �
2 Q 2Q?i. 489 ft490 ft• C
3214A p�% :r9n E�;;ct. ft ft.
NC Well Contractor Certification Number ..�r c; '?t• 7s.OUTER CASING for multi ased wells°OR LINER if a licable
AIR DRILLING INC •�� J11cQ v��'v(}tl FROM TO DIAMETER THICKNESS MATERIAL
-�- 0 ft 105 ft. 6 in.
Company Name
305539 16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: FROM I TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) fL ft i°'
3.Well Use(check well use): ft. ft, in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft. in-
❑Geothermal(Heating/Cooling Supply) nResidential Water Supply(single) ft. ft.
❑lndustriaUCommercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft' GROUT
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable
❑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 I TO DESCRIPTION color,hardness,soil/rock type in si7,eta
0 ft- 95 ft- DIRT
4.Date Well(s)Completed: 6-28-2021 Well ID# 95 IL 505 ft- ROCK
5a.Well Location: FL ft.
SPIVEY CONSTRUCTION ft ft
Facility/Owner Name Facility ID#(if applicable) ft ft.
132 PINE MEADOWS LANE, MOORESVILLE,N.C. 28117 fL ft
Physical Address,City,and Zip ft ft.
IREDELL 4636061135 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.Certifi on•
350 33.539 N 800 54.592 W
6/29/2021
6.Is(are)the well(s): [nPermanent or ❑Temporary Signature of Certified Well Contractor Date
13v signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C A100 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 peen provided to the well owner.
repair under 21 remarkr section or on the hack 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Ovice in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 505 (ft)
For multiple wells list all depths ifdifferent(example-3@200'and 2 ct 100') Submit this GW-1 within 30 days of well completion per the following:
'50 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,INC 27699-1617
Ifwater level is above casing,use"
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11.Borehole diameter 6 (in.) 24b. For Injection Wells:Copy to DWR, Underground Injection Control (IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
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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(gP m) 15 Method of test: AIR Permit Program,1611 MSC,Raleigh,NC:27699-1611
13b.Disinfection type: HTH Amount:
Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018