GW1-2022-01573_Well Construction - GW1_20220120

WELL CONSTRUCTION -
RECORD(GW�� � For Internal Use Only:
1.Well Contractor Information:
RANDY OWNBY �' A���. la,WATER ZONES
Well Contractor Name — �.�-' FROM TO DESCRIPTION
�� 289 IL 290 ft-
3214A �P' ft fL
NC Well Contractor Certification Number
` YS.OUTER CASING for multi cased'wells OR LINER ifa 1icable
AIR DRILLING INC FROM TO DIAMETER THICKNESS7 MATERIAL
0 ft. 72 ft- 6 PVC,
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: 350676 FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,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 MATERW.
❑Agricultural ❑Municipal/Public ft. ft. in.'
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑hT] atlon ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 IL 20 IL GROUT POURED
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft fL
❑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. fL
❑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,soiUrock gpe,grain sae,etc
0 1- 62 ft. DIRT
4.Date Well(s)Completed: 4- -'2021 Well ID# 62 1" 305 ft- ROCK
59.Well Location: ft. ft.
PORTER&CRESS BUILDERS ft fL
Facility/Owner Name Facility ID#(if applicable) ft. ft.
825 POTNECK RD,SALISBURY,N.C. 28147 ft. 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:
(if well field,one lat/long is sufficient) 22.Certi on:
350 46.245 N 800 31.199 w 4/8/2021
6.Is(are)the well(s): IlPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify 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#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 Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 305 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdierent(example-3 a200'and 2@100')
10.Static water level below top of casing: 50 (fL) 24a. For All Wells: Original for to Division of Water Resources (DWR),
If water level is above casing,use"+"
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
I1.Borehole diameter: 6 (in,) 24b.For Injection Wells:Copy to DWI" Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24c.For Water Supply and Open-L:'oop 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) 15 Method of test: AIR Permit Program,1611 MSC,Raleigh;NC 27699-1 61 1
13b.Disinfection type: HTH Amount:
I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018