GW1-2023-00555_Well Construction - GW1_20230104

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WELL CONSTRUCPION RECORD (GW 1) For internal Use Only:
I.Well Contractor Information:
RANDY OWNBEY
14.WATER ZONES �. y
WCllContractorNamc FROM •I'O UESCRIP'I'ION
3214A 389 —ft-390 rt.
NC Well Contractor Certitication Number ft• ft.
AIR DRILLING I N C I*t0.%I ER CASING(for multi-cascdltvells OR LINER if,a livable)`. '
I+RO�I TO DIAMETER I THICKNESS
Na -M1IATERIAL
Company ne 0. ft• 47 ft 6 I In. PVC
01=2022-164095 16.INNEI(CASING OR TUBING eothermal closed-loo
2.Well COnStruefi0n PL'I'Mit�}; G !L "_ TO DIAMETER 1 THICKNESS T MATERIAL
List all applicable well cmtsh-uction permits(l.e.UIC,County,Sane,Vurintrce,etc.) ft. ft. 1' in.
3.Well Use(check well use): n. ft. in.
Water Supply Well: 17.SCREEN -
❑ArriCultuml , DIAMETER I st.OT 617,E 7t11CKNESs MATERIAL
b ❑Municipal/1 ubhc ft. tt. in. ,
❑Geothermal(Heating/Cooling Supply) MlIesidcntial Walcf Supply(single) _--
❑Industrial/Commercial ❑Residential Water Supply(shared) ft. ft. in.
18.GROUT
❑Ini anon ❑Wells> 100,000 GPD PROM TO MATERIAL' EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well; 0 ft• 20 ft• GROUT POURED
❑Monitoring ❑Recovery tt. it.
Injection Well: j
❑A uifer Recharge ❑Groundwater 2cmediation ft. ft.
❑Aquifer Storage and Recovery ❑Salinit Barrier 1�.SAND/GRAVEL PACK if a 'livable
y RttO>I to MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑ExperimentalTeclnlology ❑SubsicicneeControl
Geothermal(Closed Loop) ❑Tracer- 211,DRILLING LOG attach additi6hal'sheets if necessary)'
❑Gcothennal(Heating/Cooling Return) ❑Other(explain under 1121 Remarks) --I TO
DESCRIPTION(color,hardness,soil/rock type, rain size,etc.
0 ft'37` rl. DIRT
4.Date Well(s)Completed: 5-3-2022 Well I D# 37 ff. 405 ft. ROCK
Sa.Well Location: ft. ft. (*
'. 'az�
ONATHAN SCRONCEt. ~ as
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Facility/Owner Name Facility 1D11(i('applieable) ft. ft. JAN p LhQ
1777 GOSPEL.DRIVEN WAY,CONOVER,N.C. 28613 ft• ft. li
Physical Address,City,and-Lip ft. ft. ftiti+
CATAWBA 374516738697
County Panel Identification No.(PIN)
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5b.Latitude and longitude in degrecsltninutes/seconcis or decimal degrees; --._—
(ifwcll field,one lat/long is sufficient) 22.Cer
350 48.325 N 800 11 .565 W 573/2022
6.ls(are)the well(s): [!]Permanent or ❑Temporary Signnrurc ofCertificd Well Contractor Dale
1Jr.signiug d,is.%ornt,thereby c_ertify that the wells)was(were)constructed fn accordance with
7.Is this a repair to ail existing well: ❑Yes or MNo 1 i:f A'CAC 02C.0/i10 or 15A NCAC 02C.0200 H'e11 Construction Standards and that a copy
Ifthis is a repair,fill out known well construction in%rnmtion and explain the nata-e of 1he q/'rhi.s recnrcd has been provided to the Iv ll owner,
repair tinder 1121 remarks section or on the back of 1his form.
23.Site dingr:un 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 NUMi F of wells (add'See Over'in Remarks Box).You may also attach additional pages if ncccssary.
drilled:
-"—' 24.SUBMITTAL INSTRUCTIONS'
9.Total well depth below land surface: 405
For mtdtlplewelds list all depths ifdocrent(eample-3a200'ond?@q00') (ft) Submit this GW-1 within 30 days ofwell completion per the following:
10.Static water level below top of easing: 50 (ft) 24a. For All Wells: Original form to I Division of Water Resources (DWR),
Ifwater/eve/is above casing,use Inli)rmation Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b. For Iniection Wells: Copy to DWR, Underground Injection Control(IUC)
Program, 1636 MSC;Raleigh,NC 27699-1636
12.Well construction method-. I
(i.e.auger,rotary,cable,direct push,etc.) 24c.For Water'Supply and Open;-Loop Geothermal Return Wells:Copy to the
county environmentat health department of the county where installed
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FOR WATER SUPPLY WELLS ONLY: 24d. For Water Wells producing over 100,000 GPD•Copy to DWR,CCPCUA
13a.Yield(gpm) 6 Method of lest•AI R Permit Program, 1011 MSC,Raleigh,NC 27699-1611
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13b.Disinfection type: HTH Amount: i
Form OW-I North Carolina D'epartmcnt of Environmcnud(laalily-Divisioa of Watcr Resources { Revised 6-6-2018
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