GW1-2022-01565_Well Construction - GW1_20220120

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
RANDY OWNBY
14.WATER ZONES
Well Contractor Name � +,�" �l! ,,;� FROM TO ft DESCRIPTION
ft
3214A ! 10` ` 249 250
ft ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells DR LINER if a licable
AIR DRILLING INC ,Pk C`�Jj� FROM ftflTO ft DIAMETERm THICKNESS MATERIAL
0 38 6 PVC
Company Name z
354569 ` J 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit th c'�',' FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UiC,County,Slete, variance,etc.) ft ft. in.
3.Well Use(check well use): ft. ft. m•
Water Supply Well: 177.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) IlResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 19.GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 €t 20 €a GROUT ' POURED
❑Monitoring ❑Recovery ft. ft.
injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK ifa licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft 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 421 Remarks) FROM TO DESCRmTION color,hardness,soivrock type,grain size,etc.
0 €t 128 €t• DiRT
4.Date Well(s)Completed: 4-28-2021 Well ID# 128 fL 265 ft- ROCK
ft. ft.
5a.Well Location:
JOEL RITCHIE ft ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
150 DEER TRACK LANE,SALISBURY,N.C. 28147 fL ft.
Physical Address,City,and Zip ft. ft.
ROWAN 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one IatAong is sufficient) 22.Certific
350 38.519 N 800 23.434 w 4/28/2021
6.Is(are)the well(s): IlPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certh,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.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=2/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: 265 (ft)
For multiple wells list all depths i(dierent(example-9@_)200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 20 (fL) 24a. For All Wells: Original form 'to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
I�w61er love!is above caring,use"=" I
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: Copy to DWR, Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
Well construction method: 24c.For Water Supply and Opcn-Lo6 plGeothermal Return lYe'Is: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) Method of test: AIR
Permit Program,1611 MSC,Raleigh,NC 27699-1 61 1
j
13b.Disinfection type: HTH Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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