GW1--00661_Well Construction - GW1_20240119

WELL CONS'I'RTJC'I'ION RECORD CW-1
For Internal Use Only:
I.Well Contractor Information: I -
RANDY OWNBEY I , I
Well Contractor.Name
14,WATER ZONES 1 I —�
Fit011 TO DESCRIPTION
3214A 289 fL 290 I —--_
NC Well Contractor Certification Number It ft.
• AIR DRILLING I N C 15.OUTER CASING(for multi-cased''ells)OR LINER(li so tlicable)
PROM TO DIAMETER THICKNESS_ MATERIAi.
Company Name0 ft. 77 fI i to. GALV — —
2.Well Construction Permit 1): 2022-8624 16.INNER CASING OR TUBING(Aeotherial closed-loop)
FROM TO DIAMETER THICKNESS ,11:11'ER A1_
List all applicable well construction permits'ae.VIC,County,Slate, Variance.etc.) _
3.Well Use(check well use): --— —---_—_._
Water Supply Well:
17.SCREEN I —_yawl
IJ!\gl'lellhllr:,) , FRl TO nLLMt rh:Ri ._si.n•rSIZE ESS THICKNESS s7Art•:Rz, .-
❑Municipal/lublic ft. ft. in) --
•
h.IGeolhcrnral(I lealing/Cooling Supply) t'IResitlential Water Supply(single) —_
I.Ilnthrsn'ial/Commercial ft. It. in. "
❑Residential Water Supply(shared)
C11rri)atiolt IS,GROUT
❑Wells> 100,000 GPD FROM TO MATERIAL EMi'LACILSIILNTMETIitlt&AMOUNT
Non-Water Supply Well: 0 ft 20 r'• GROUT POURED
lil\Aunitoring I�Recovery ft. — — ft. -----7 --- .__.
Injection Well::
it\yiiilcrRcchtgc I_IGruuntvalcrRcmetliution -- ft --f—t---- — —
17Aquil'cr Storage and Recovery lJSalinity Barrier 19,SAND/GRAVEL PACK(if npplictible) ——
FROAI TO MATERLI I• INNpLACEMENTNIPTI'IIOD
ClAyuilerThsl OSlormwatcrDrainage ' ft. ft. "
_ I
ClExperimcntal'l'echnology 1:Subsidence Control — -- --------_ ._.__
ft, fl. i
f:JGcolhcrmal(Closed Loop) ElTracer 20.DRILLING LOG(attach additional sheets if necessary)
6_
E1Cieothcrmal(I tenting/Cooling Return) ElOther(explain under//21 Remarks) FROFROMt'D DESCRIPTION(color,hardness,son/melt I�m.•lulu size,eic)
0 rt.
67 f'• DIRT I, , L ._—.
4.Date Well(s)Completed: 2-10-2023 Well ID// 67 ''' 305 ft ROCK
5a.Well Location: ft. ft.
DIANE HUMPHREY rt. ft. 1
Facility/Owner Name Facility 11)(1(it'applicsble) ft• Ii• 11 — —
170 RINEHARDT RD,MOORESVILLE,N,C. 28117 -• 4'}�' '
fL ft. i . I . > _ ti y;r;'rI
' �W 4.,h L,,,•
Physical Address,City,and Zip ft. ft. l.-- -- JA P,
IREDELL . 4658817554 21.REMARKS - 9 tGZ —�
I in ;fi.^'; O -,County Parcel Identification No.(PIN) I, n : r �.�,2
urf. •
)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: — d'+6J` Ll(j
ti11well field.One lat/lun);is suflleicnt) -- — --—----- ----- -
35° 36.536 N 80° 49.258 22.C,er(irca '
" 2/10/2023
6.Is(are)the well(s): 1!1Pernnutcnt or ❑Temporary Signmu aol'Catil' Well ontrnclOr , D,ue
By signing this'/brat.I hereby cerli/i'(hot Ihcisred!(t)was(11.019 constructed in urrordunrr Hall,
7.Is this a repair to an existing well: DYes or LINO /54 NCAC'02C.0100 or I5A NC tC(02C.0200 II'e!l Construction Standarr/.s and that a cum
Obis is a repair.fill out known well construction inlbr•mation and explain dm nature Rflhc q/this rervrrd has been proridcd ro fire wet!nos,er.
• repair tole-112/remarks section or an the back v./wax fin•w.
23.Site diagram or additional well details:
S.her Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back ol'this page lob provide additional well construction info
(add'See Over'in Remarks Box).You may also attach additional pages il'n ccssary,
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells
________
' 24.SUBI\'IITTAL.INSTRUCTIONS I
9.Total well depth below land surface: 305 (ft.)
For multiple wells list all depths lfdi/Jcrent(example-3©200'and 2 a 100') Submit this GW-1 within 30 days of well completion per the following:
(fL) 24a. For All Wells: Original form to Division of Water Resources (DWR),
(O.Static water level below top of casing: 30
limiter level is above casing,use"•a•' Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
I I.Borehole diameter: 6 (in.)
24h.For Injection Wells: Copy to DWR, Underground Injection Control (MCI
Program, 1636 MSC,Raleigh,NC 2 76 99-1 63 6
12.Well c'olstructio It method: i j
(i.e.auger.
rotary.cable.direct push.etc.) 24c.For Water Supply and Open-.trip Geothermal Return Wells:Copy to the
county environmental health dcpmlment of the county where installed
FOR WATER SUPPLY WELLS ONLY:
24d1.For Water Wells producing overt 100,000 GPI): Copy to DMZ.('('P('l I;\
13:r.Yield(gpnr) 60 Method of test: AIR Permit Program, 1611 MSC,Raleigh,NC 27699-1 6 1 1
13b.Disinfection type: HTH Amount: II
Form G W-I North Carolina Department of Environment'Quality-Division of Water Resources
(revised G-h-.!p IS
, ,