GW1--00584_Well Construction - GW1_20240118

WELL CONSTRUCTION RECORD GW-1) ForPrint Form
Internal Use Only: 1
1.Well Contractor information:
RANDY OWNBEY ,
14.WATER ZONES
Well Contractor Name FROM '1'0 DESCRIPTION
•
3214A 389 ft• 390 rt: I
NC Well Contractor Certification Number ft. ft.
AIR DRILLING INC 15.OUTER CASING(for multi-cnsediwclls)OR LINER(if ap licablc)
FROM TO DIAMETER I TIIICKNESS MATERIA1,
Company Name 0 ft. 62 ft. 6 I , In. PVC
1049 16.INNER CASING OR TUBING(geothermal closed-loop)
L2.Well Construction Permit#: FROM To DIAMETER TIIICKNESS MATERIAL
ist all applicable tre!l 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 ,
Agricultural FROM TO DIA\14.rER SLOT SIZE 'I'IIICKNESS \IA'I'ER IA I,
OMunicipal/Public ft. ft. in, —
,Geolhcrntal(heating/Cooling Supply) DiResidential Water Supply(single) _
lndustrial/Commercial fl, ft. In.
Water Supply(shared)
IS.GROUT
Irrigation FROM TO.
MATERIAL E\IPI.,\CEMIiN'f dIF;fIIOD&AMOUNT
Non-Water Supply well: 0 rt• 20 rL GROUT
Monitoring POURED
Recovery ft. ft. —
' - Injection Well:
ft.
Aquifer Recharge �Groundwatcr Remedial ion D/ ft.
Aquifer Storage and Recovery19.SAND/GRAVEL PACK(If applicable)
DSalinity Barrier FROM TO MA'rcRL\I• ii5IPLACEMENT METHOD
Aquifer Test QlStormwater Drainage ft. ft.
Experimental'losedechn loop Subsidence Control ft. ft•
Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets If necessary)
Geothermal(Heating/Cooling Return) rlIOther(explain under#21 Remarks) FROM ro 0 ft' 52 ft• D DISSCItl P'1'ION(color,Onntset,,suiurueS type,{ram sirs,etc.)
DIRT
4.Date Well(s)Completed: 11-3-23 Well ID// 52 ft. 405 ft'
ROCK
Sa.Well Location: ft. ft. — —
LORI BROWN
rt. ft.
Facility/Owner Name Facility 1D11(if applicable) ft. ft. P j'- ��p L 1
1474 DRACA RD,LENOIR,N.C. ri, ft. --
Physical Address,City,and Zip ft. R.
CALDWELL 2890-53-0813 21.REMARKS irtf ;•'T,?•i4^..il P!':„:`y�'etiz-g li-r,j
County Parcel Identification No.(PIN) Vr3O
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
of well field,one lat/long is sufficient) 22.Certifi , n:
35° 56.173 N 81° 22.852
W i 11-3-23
6.Is(are)the well(s)OX Permanent or OTemporary Signature ofCerti fed Well Contractor ! Date
Ihy signing this firm, I hereby certifi•that the weld(e) ills(were)constructed in accordance,
7.Is this a repair to an existing well: DYcs or 'X0No wilh/S,I NC/IC 02C.0/00 or 15.'l NC',IC'02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction Ir fbrumtion mid explain the nature of Me copy of this record has been Provided io'the well owner.
repair under 1121 remarks section or on the back ofthisforte.
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal'Wells having the same You may use the back of this page to provide additional well site details or well
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also,attach additional pages necessary.
drilled:
405 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list/all depths(/'d(/,)ivcnl(example-.i@200'and 40 fl0')
construction to the following:
10.Static water level below top of casing: 60 (ft.) Division of Water 12esorirces,Information Processing Unit,
!f water lorel is above casing,use +„
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.)
24b. For Injection Wells: In addition to sending the form to the address in 2.4
12.Well construction method: above, also submit one copy of this font within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construct to the following: lion
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Cpepnter,Raleigh,NC 27699-1636
13a.Yield(gpm) 12 Method of test: AIR 24c. For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this (form within 30 days of
13b.Disinfection type:HTH Amount: completion of well construction to the county health department.of the county
where constntcted.
Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources
Revised 7.-22-7.016