GW1-2022-01568_Well Construction - GW1_20220120

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: f
I.Well Contractor Information:
RANDY OWNBEY q
14.WATER ZONES P }
Well Contractor Name FROM TO I ESCRIM'ION
3214A
2 q 2Q?�. 289 fL 290 ft. G
n ft. ft. !
NC Well Contractor Certification Number �� �;:11. I
AIR DRILLING INC ,, r c "15.OUTER CASING for multi-cased wells OR LINER ifa licable
.,r�i15 •�-� FROM TO DIAMETERS THICKNESS MATERIAL
Company Name " �j�;a - 0 fL 90 fr. 6 PVC
354981 16.INNER CASING OR TUBING eothermal closed-loo
2.WCII Construction Permit#: FROM I TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County.ty.Sale, Variance,etc.) fL ft.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO I DIAMETER I SLOTSIZE I THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public fr. fL in.
❑Geothermal(Heating/Cooling Supply) It Residential Water Supply(single) ft. fL in.i
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑WeIIS>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 20 ft- GROUT POURED
❑Monitoring ❑Recovery R. 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 EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage ft. R•
❑Experimental Technology ❑Subsidence Control fL ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOC attach additional sheets if necessa
❑Geothenmal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain sae,etc.
0 It. 80 fL DIRT
4.Date Well(s)Completed: 10-12-2021 well ID# 80 fL 305 ft. ROCK
5a.Well Location: ft. ft.
BARNHARDT CONSTRUCTION ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) fL ft.
144 LOCHSHIRE LANE, WOODLEAF,N.C. 27054
Physical Address,City,and Zip ft. ft.
ROWAN 8174050 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.Cer ation•
350 45.360 N 800 34.348 W 10/12/2021
6.Is(are)the well(s)• MPermanent or ❑Temporary Signature of Certified Well Contractor Date
Ay signing this•form,I hereby certify that the well(5)was(were)constructed in accordance frith
7.Is this a repair to an existing well: ❑Yes or I!INo ISA NCAC 02C.0100 or 15A NCAC 02C.6200 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 wider t:21 remarks section or on the back oJthis 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 I GW-I 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: 305 (ft.)
Eor multiple wells list all depths ifelierent(eratnp/e-3@200 and 2 a 100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 50 (ft.)
ft 24a. For All Wells: Original form Ito Division of Water Resources (DWR),
IJ,vater level is above casing,tore"+" ) Information Processing Unit,1617 MSC„Raleigh,NC 27699-1617
11.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-Loon 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) Method of test:
AIR Permit Program,1611 MSC,Raleigh,NC 27699-1611
i
13b.Disinfection type: HTH Amount:
i
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources f� Revised 6-6-2018