GW1--00647_Well Construction - GW1_20240119

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
RANDY OWNBEY u.WATER ZONES j
Well Contractor Name • FI20M I'O DESCRIPTION
3214A 249 ft. 250 ft. 1 l -
ft. ft.
NC Well Contractor Certification Number t
15.OUTER CAS1NG for multi-cased svellsLOR LINER(If applicnb)
AIR DRILLING INC FROM'' ((''TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 160 ft. 0 hi. I PVC
378053 - 16.-INNER CASING OR TUBING(geothermal closed-loop)
Z.Well Construction Permit#: PROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Let.(//C,County,State,'Variance,etc.) ft. ft. i In.
3.Well Use(check well use): ft. ft. i In.
Water Supply Well: 17,SCREEN
Agricultural FROM ' •ro DIAMETER SLOTSizi: THICKNESS MATERIAL
g oMunicipal/Public ft. ft. hi.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT SIETIIOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. GROUT POURED
Monitoring DRecovery rt. ft.
Injection Well:
It. ft.Aquifer Recharge 0Groundwatcr Rcmcdiation Aquifer Stora c and Recovery19.SAND/GRAVEL PACK Of applkable) -.
g DSalinityBarrier FROM 'TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStonnwater Drainage ft. ft. ,
Experimental Technology DSubsidcnce 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 ' 'ro DESCRIPTION(color,hardness,solt/rock type,grain size,etc.)
0 ft. 50 ft. DIRT
4.Date Well(s)Completed: 08-17-2023 Well ID/► So (!'^ -
ft. 265 ft' ROCK C^'.'j.`.--e--d P_._?3 fri -'
Sa.Well Location: ft, ft. - v�.b..,0 k.a..i, V uz
JEFF MOORE ft. ft. JAN 1 9 2g24
Facility/Owner Name Facility ID#(if applicable) et. ft.
;riff ,�:.:1;?l r.t- v 1845 GODBEY RD,SALISBURY,N.C. 28147 rt. ft. ;:.r3 Utz
Physical Address,City,and Zip ft, ft.
ROWAN 825-029 • 21,REMARKS' -
County Parcel Identification No,(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decitnal degrees:
(if well field,one lat/long is sufficient) 22.Certif . on:
35°44.102 N 80° 35.275 W
08-17-2023
6.Is(m e)the wells) Permanent or �I1'empornry Signature of Certified Well Contractor Date
By signing this fora(,I hereby certify thatlthe we/!(t)was(were)constructed in accordance
7.is this a repair to an existing well: DYes ot• DNo with 1SA NCAC 02C.0100 or ISA NCAC 02C.0200 if ell Construction Standards and that a
If this is a repair,fill out known well construction i fornration and explain the nature of the copy of this record has been provided to the well owner.
repair under 1121 remarks section or on the back al this Amt. l
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprohe/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 necessary.
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well depth below landsm face: 265 (ft.) 24a. For All Wells: Submit this form within 30 days of completion o1•well
For multiple ltiple wells lie!all depths(I diffrrenl(example-3@200'and 2(:al00') construction to the following: I
10.Static water level below top of casing: 50 et,
( ) Division of Water Resources,Information Processing Unit,
If water level is those casing,use"+" 1617 Mail Service Cedtei',Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b, For injection Wells: in addition Ito sending the form to the address in 24u
12.Well construction method: above, also submit one copy of this ifoi•n)within 30 (lays of completion of well
(i.e.auger,rotary,cable,direct push,etc.)
construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 15 Method of test: AIR 24c. For Water Supply& Iniectioi Wells: In addition to sending the form to
the address(es) above, also submit lone copy of this form within 30 days of
13b.Disinfection type: HTH Amount: completion of well construction to tic,county health department of the county
where constructed. i
Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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