GW1--00578_Well Construction - GW1_20240118

i•CORD GW-1 Print Form
WELL CONSTRUCTION RECORD •
For Internal Use Only: - ---- -
1.Well Contractor Information:
RANDY OWNBEY
14,WATER ZONES
Well Contractor Name
FROM TO DESCRIPTION
3214A 349 ftl 350 ft.
NC Well Contractor Certification Number It ft,
AIR DRILLING INC 15.OUTER CASING(for multi-cased swells)OR LINER(If apelicnbic)
FROM TO DIAMETER' THICKNESS MATERIAL
Company Name 0 ft. 197 ft. 6 I !in. PVC
2.Well Construction Permit#: 08-2023-202588 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL —
Lis!all applicable well construction permils(i.e.UIC,County,State,Variance,etc.) ft. ft. i ,in, —
3.Well Use(check well use): ft. ft. ! in.
Water Supply Well: 17.SCREEN
Agricultural FRO\7 TO DIAi\1F:1'F.R SLO'1'SI%F: THICKNESS \IA'I'IsR IA I,.
DMunicipal/1 ublic •
n, ft. in..
Geothermal(Heating/Cooling Supply) Residential,Water Supply(single)
ft. ft. in.
lnduslrial/Commbreial ['Residential Water Supply(shared)
irrigation 18,GROUT
FROM TO MATERIAL, EMPLACEMENT METHOD 4.AMOUNT
Non-Water Supply Well: 0 ft 20 ft. GROUT POURED
Monitoring Recovery
Injection Well: ft. ft.
Aquifer Recharge [�Groundwatcr Rcntcdiation ft. ft.
Aquifef Storage and Recovery19.SAND/GRAVEL PACK(if applicable)
SRIIIIityBalTier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology QSubsidenec Control ft, ft.Geothothermrmal(Closed Loop) ❑ITracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO pESCRI P'I:ION(color,hardness,soli/roes type,prate sirs,etc.)
0 ft. 87 ft. DIRT i
4.Date Well(s)Completed: 09-20-23 Well ID// 87 ft. 365 ft. ROCK
5a.Well Location: ft. (t,
ELITE BUILDERS ft. ft. ;( ' ,
Facility/Owner Nana.; Facility LW/(if applicable) ft. ft.
3954 CEDAR WOOD TRAIL,TERRELL,N.C. 28682 ft. R.
JAN 1 S 2024
Physical Address,City,and Zip ft, ft.
CATAWBA 461704733329 2l.REMARKS I`f7,:Tr-FL:in)Pr'7"•.71.•'�'a Un:1
Dt,)1:OJF.rI.
County Parcel Identification No.(PIN) •
i
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Ial/long is sufficient) 22.Cerf ,lion
350 35.031 N 80° 57.360
w 9-20-23
6.Is(are)the well(s)JX Permanent or D'Temporary Signature ofCeriilieil Well Contractor Date
By signing this fora,,/hereby ccrt(/l'that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or DNo with 154 NCAC 02C•.0/00 or/54 NCAC 02C.0200!Veil C.'onst•uction Standards and that a
If Mix is a repair,fill out known well constructionit formation and explain the nature of the Copy alibis s record has been provided to the well owner.
repair under 021 remarks section or on the back()phis Jorn,.
23.Site diagram or additional well details:
You may use the back of this page tolprovide additional well site details or well
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if accessary,
drilled:
SUBMI'I'TAI,INSTRUCTIONS '
9.Total well depth below land surface: 365,.
For multiple wells list all depths ifdiffirent(cean,ple-?a 200'and 2 cu/nn') VW 24a, For All Wells: Submit this form within 30 days of completion or well
construction to the following:
10.Static water level below top of casing: 30 t r
i llwer level isabove casing,use"-F" (f ) \ Division of N ater Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 I
(in.) 24b. For Injection Wells: in addition`to sending the form to the address in 24a
12.Well construction method: about, also submit one copy of this felon within 30 days of completion of well
•
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
1
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
. 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 5 Method of test: AIR . 24c. For Water Slimily & Injection wells: in addition to sending the firm to -
HTH • the address(es) above, also submit ode [copy of this form within 30 clays of
131).Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form OW-I North Carolina Department cif Environmental Quality-Division of Water Resources Revised 2-
27.-7.0I6