GW1-2022-01530_Well Construction - GW1_20220120

WELL CONSTRUCTION RECORD(GW-1 For Internal Use Only:
1.Well Contractor Information: o N
RANDY OWENBY e �, la.WATER ZONES r
Well Contractor Name �e FROM TO DESCRIPTION
3214A 549 ft- 550 ft
o` ft. ft
NC Well Contractor Certification Number i
Via` >✓� 15.OUTER CASING for multi cased wells OR LINER if a licable
AIR DRILLING INCH FROM TO DIAMETER I THICKNESS MATERIAL
'`a~'a 0 rL 166 ft. 16 in. PVC
Company Name a+'
243576 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.U1C,County,State, Variance,etc) ft ft fin.
3.Well Use(check well use): It. It. in.
17.SCREEN
Water Supply Well: 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.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lrri ation ❑Wells>100,000GPD FROM TO I MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 IL 20 ft GROUT POURED
❑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 To DESCRIPTION color,hardness,soillrock type,grain sire,etc.
0 IL 56 ft DIRT
4.Date Well(s)Completed: 1-19-2021 Well[D# 56 IL 565 ft' ROCK
5a.Well Location: ft. ft.
LAKEMIST HOMES ft It.
Facility/Owner Name Facility iD9(if applicable) ft. ft.
215 HIDDEN MEADOWS,MOORESVILLE,N.C. 28117 IL ft
Physical Address,City,and Zip ft. ft.
IREDELL 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.Ce catic
350 37.578 N 800 52.526 W100 1/19l2021
6.Is(are)the well(s): InPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,/hereby certtfy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or InNO 15A 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'121 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-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: 565 (ft.)
For multiple wells list all depths rfdr(ferenr(example-3@200'and 2@100') Submit this GW-I within 30 days of well completion per the following:
i
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,NC 27699-1617
/fwater level is above casing,use i
t 1.Borehole diameter: 6 (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
t
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) 12 Method of test: AIR
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018