GW1--00660_Well Construction - GW1_20240119

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: __ _- --
1.Well Contractor Information:
RANDY OWNBEY I I
14.WATER ZONES '1 I
Well Contractor Name FROM TO DESCISIP rtoN
3214A 549 ft, 550 ft, I I
rr. ft. I I •
NC Well Coninrcior Certification Number
15.OUTER CASING(for multi-cased liens)OR LINER(trap licablc)
AIR DRILLING INC FROM TO DIAMETER THICKNESS MATERIAL _
CompanyNamc 0 ft. 75 ft. 6 1' ill. PVC
2023-19326 16.INNER CASING OR TURING(geothermal closed-loop)
2,Well Construction Permit#: FROM •rn DIAMETER THICKNESS MATERIAL,
List all applicable it'll construction permits(i.e.1/IC,County,State, Variance.etc.) ft. ft. ink ---
3.Well Use(check well use): rt. ft. I in. --
Water Supply Well: 17.SCREEN
FROM TO DIAMETER!. -SI,O't'SIZE THICKNESS \IATER At,
0Agricultural Municipal/Public ft. ft. in:
Geothermal(I-Ieating/Cooling Supply) XQIResidential Water Supply(single)
ft. ft. in.
industrial/Commercial �Residenlial Water Supply(shared) 18,GROUT
liTigation FROM TO ii
MA'1'ERn\I, EAIPLACEMEN'r ammo S'AMOUN'I'
D
Non-Water Supply Well: Q ft. 20 n. GROUT POURED
•MonitoringRecovery ft. ft.injection Well:
fl, ft,Aquifer Recharge DGroundwatcr Renediation
Aquifer Storage and Recovery �^�Salinit Barrier 19,SAND/GRAVEL PACK(if applicable)
LY Y FROM To MATERIA.• F\•IPL,\CEftIF.N'f\Ita'II(111
Aquifer Test DStormwatcr Drainage ft. ft.
'Experimental Technology Subsidence Control R. • rt._
Geothermal(Closed Loop) Tracer 20,DRILLING LOG(attach ndtlitionhl sheets If necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM ro DESCIRIP1t'ION(cater,hardness,sail/reek type,grain size,'ele.)
0 ft. 65 ft• DIRT
4.Date Well(s)Completed: 10-4-23 Well ID# 65 tt' 565 ft• ROCK
Sa.Well Location: ft. ft. I, - _
LE BEAM CONSTRUCTION • ft. ft. ,
Facility/Owner Name Facility Ill1!(il'applicable) 1't. ft. 1 (;,.± 4 :�, :+ r
122 AKFARA LANE,TROUTMAN,N.C. 28166 rI rt. Q-
�'' ]
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Physical Address,City,and Zip - ft. ft. L J/t\J 1 9 -0
IREDELL 4730-80-0735 21.REMARKS
tnizriter i^7 7r�`..r
County Parcel Identification No.(PIN) i 'u„?9 G''a
I• `'.y l�ii ��„Z�3
51).Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Orwell field,one lat/long is sufficient) 22.Certifi on:
35° 39.659 N 80° 53.5124--4"--i.
W
10-4-23
(.Is(are)the wells) X Permanent or ❑I'1'empm to}' Signature of Certified Well Contractor .1 Date
/3y signing This farm, l herehv cervi/i'that The well(s) was(reeve)constructed hi accordance
7:Is this a repair to an existing well: DYes or 0No with 15A NCAC'02C'.0100 or/5.1 NC,IC102C.0200 troll Construction Standards and Th !a
If'this is a repair•fill out known well construction h formation and explain the nature of the eaPP of tlr/s regard has been provided to the well owner.
repair under 021 remarks section or on the back q/'this form.
23.Sfte diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You Tay 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 if necessary.
drilled: SUBMITTAL INSTRUCTIONS 1
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9.'fatal well depth below land surface: 565 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of will
For rrdtiple trolls list all depths ifdiff'reut(example-3@200'200'and 2 rr/00') construction to the following:
10:Static water level below top of casing: 50 (ft.)
Division of Water Resources,information Processing Unit,
I(water/crc•Iis above cursing,use"t" 1617'tail Service Cetiter,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b. For Injection Wells: in addition to sending the form to the address in 24a
above, also submit one copy of this,fom\ within 30 days of.completion of well
12.Well construction method: construction to the following:
-(i.e.auger,rotary,cable,direct push,etc.) 1
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY:
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 8 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
13 b.Disinfection type:HTH Amount: completion of well construction to the Icounty health department of the county •
where constructed.
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Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016
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