GW1-2022-01523_Well Construction - GW1_20220120

WELL CONSTRUCTION RECORD(GW-1)��,,, For Internal Use Only:
P yI
1.Well Contractor Information: I
RANDY OWNBY 14.WATERZONES
Well Contractor Name FROM TO DESCRIPTION
�
v •(.... ,
o �;�:C,� 289 fr• 290 It.
3214A ,
`, '•,t�` ft. 95 ft. j
NC Well Contractor Certification Number ,� �^��� 15.OUTER CASING for'mul=sed wells OR LINER if a livable
AIR DRILLING INC -'.. FROM TO DIAMETER THICKNESS MATERIAL
J' ft ft �in:
Company Name
311576 ``+ 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 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.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER --;SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) PJResidential 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 fL 20 ft- GROUT
❑Monitoring ❑Recovery fa ft.
Injection Well:
ft ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a livable
❑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,soiVrock type,grain sae,etc.
0 ft 85 ft. DIRT
4.Date Well(s)Completed- 3-5-2021 Well ID# 85 ft 305 ft- ROCK
ft ft.
5a.Well Location:
DAVID T MARTIN f`'
Facility/Owner Name Facility ID#(if applicable) ft ft.
134 COTTAGE CT, MOORESVILLE,N.C. 28117 ft ft.
Physical Address,City,and Zip ft ft
REDELL 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.Certifie
350 38.411 N 800 49.202 W 3/5/2021
6.Is(are)the well(s): ❑Permanent or ❑Temporary Signature of Certified 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 ONo 15A NCAC 01C.0100 or 15A NCAC 01C.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 depths if dierent(example-3@200'and 2@100')
40 24a. For All Wells: Original form Ito Division of Water Resources (DWR),
f Static water level below top of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
IJwater level is above casing,use"+"
I1.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
1
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gP m) 5 Method of test: AIR Permit Program,1611 MSC,Raleigh,NC 27699-1 61 1
13b.Disinfection type: HTH Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018