GW1-2022-01535_Well Construction - GW1_20220120

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WELL CONSTRUCTION RECORD(GW-1) ,, For Internal Use Only: �
1.Well Contractor Information:
NEILL PARDUE "^y
�';,•,� .�� 14.WATER ZONES i
Well Contractor Name
,rev + i1.' FROM TO DESCRIPTION
� �' ��,
609 fL 610 ft
2609A r'
ft ft.
NC Well Contractor Certification Number �G c� Is.OUTER CASING for multi cased wells OR LINER if a licable
AIR DRILLING INC 3.},�', FROM TO DIAMETER! THICKNESS MATERIAL
0 fL 40 ft. 6 in.
CompanyName PVC
,°�`
312308 i 16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,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 ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) In Residential Water Supply(single) ft. ft. in.
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) I&GROUT
❑Irri ation ❑Wel Is>100,000 GPD FROM TO MATERIAL, EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 20 ft- GROUT POURED
❑Monitoring ❑Recovery fL ft.
injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK ifa licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage f4 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,soil/rock type,grain sae,etc
0 ft> 30 ft- DIRT
4.Date Well(s)Completed: 2-10-2021 Well ID# 30 ft 625 ft- ROCK
5a.Well Location: ft ft
LYNN SHIRE LLC/STEVE KNIGHT ft- fL
Facility/Owner Name Facility fDff(if applicable) ft. ft.
129 EMPERORS TRAIL, MOORESVILLE,N.C. 28117 fL ft.
Physical Address,City,and Zip ft. ft.
I REDELL 21.REMARKS
County Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Iattlong is sufficient) 22. ;4�&
350 36.239 N 800 47.205 W 2/10/2021
6.Is(are)the well(s): OPermanent or ❑Temporary Si tore o Ceni a We Contracto Date
By signing this form,/hereby certify that the well(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 02C.0200 Well Construction Standards and that a copy
Ifthis 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 deta0s:
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: 625 (ft)
For multiple wells list all depths ifdi ferent(example-3(200'and 2 a 100') Submit this GW-1 within 30 days of well completion per the following:
30 24a. For All Wells: Original form to;Division of Water Resources (DWR),
10.Static water level below top of casing: (fL) (nformation Processing Unit,1617 MSC,Raleigh,NC 27699-1617
/f water level is above casing,use
11.Borehole diameter: 6 (in,) 24b.For Injection Wells: Copy to DWR, Underground Injection Control(fUC)
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
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing_ove1r 100,000 GPD:Copy to DWR,CCPCUA
139.Yield(gpm) 3 Method of test: AI R
Permit Program,1611 MSC,Raleigh,i C,27699-1 61 1
13b.Disinfection type: HTH Amount:
Form G W-1 North Carolina Department of Environmental Quality-Division of Water Resources f Revised 6-6-2018