GW1-2022-01537_Well Construction - GW1_20220120

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
RANDY OWENBY 1a.WATER ZONES
Well Contractor Name, l FROM TO DESCRIPTION
3214A 229 ft. 230 It.
ft. ft.
NC Well Contractor Certification Number
y= • .6 15.OUTER CA for mold-cased wells OR LINER if a licable
AIR DRILLING INC DIAMETER THICKNESS MATERIAL
Company Name nT�"i ` 0 ft- 41 ft- 6 1II PVC
AP-306117: 16.INNER CASING OR TUBING eothermal closed400
2.Well Construction Permit#: �y�'• FROM TO DIAMETER ! THICKNESS IMATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) It. 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.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 1` GROUT POURED
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage fL ft.
❑Experimental Technology ❑Subsidence Control It. 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,soiUmck e,grain sae,etc.
0 ft- 31 ft- DIRT
4.Date Well(s)Completed: 1-1 1-2021 Well ID# 31 ft 245 ft- ROCK
Sa.Well Location:
ft. ft.
LORETA RUIZ It. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
139 SPARTA DR, MOORESVILLE, N.C. 28115 ft. 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 lat/long is sufficient) 22.Ce on•
350 37-546 N 80° 51.020 W 1/11/2021
6.Is(are)the well(s): CJPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the wel ll(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or I!lNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
tt 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 Ovee in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 245 (ft.)
For multiple wells list all depths ifdifjerent(example-3@200'and 2 rt 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),
Ijwater[evel is above casing,use f Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,1Raleigh,NC 27699-1617
"-"
II.Borehole diameter: 6 (in,) 24b. For Injection Wells:Copy to DWR,:Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699 t-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 over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm)
80 Method of test: AIR Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
13b.Disinfection type: HTH Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources III Revised 6-6-2018