GW1--00709_Well Construction - GW1_20240119

WELL CONSTRUCTION RECORD GW-IPrint Form
Forinternal Use Only:
I.Well Contractor Information:
RANDY OWNBEY I
Well Contractor Nam 14,WATER ZONES I
FROM TO DESCRIPTION
3214A 429 ft, 430 ft.
NC Well Contractor Certification Number ft' fl,
AIR DRILLING INC ' IS.OUTER CASING(for m (ii'
ultl-cased wells OR LINER ap licable)
FRO'1 TO DIAMETER 'THICKNESS MATERIAL
Company Name rt. 60 ft. 6 in. PVC
2023-32851 16.INNER CASING OR TUBING(geothermal closed-loop)
2,Well Construction Permit d: FROM ' TO ' DIAMETER THICKNESS MATERIAL
List all applicable well co,txtruc•rion permits(i.e.WC,County,Sane, Variance,etc) ft. ft. I i in,
3.Well Use(check well use): 1 I
I'I. ft. I I in.
Water Supply Well: • 17.SCREEN I ,
A 1'ICllllnl'nl FROM TO DIAS IETEISI 'SLOT'SIZE THICKNESS MATERIALb OMunicipal/Public ft. ft. in:,
Geothermal(Heating/Cooling Supply) X[]IRcsidcntial Water Supply(single) ------
tn.
Industrial/Commercial Residential Water Supply(shared) ft,
—1In•igalion ]S,GROUT rt.
FROM TO MATERIAL EMPLACEMENT stierIIOD A AMOUNT
Non-Water Supply Well: 0 ft' 20 ft' GROUT POURED
Monitoring DRecovery ft. ft. ---
Injection Well: j
0Aquifer Recharge DGroundwatcr Rcmcdiation ft. ft. I
❑Aquifcr Storage and Recovery IDSalinity Barrier 19.SAND/GRAVEL PACK4If applicable)
FROM' TO MATERtAt. EMPLACEMENT METHOD
0Aquifer Test DStormwatcr Drainage ft. ft. 1
0Experimental Technology IDSubsidence Control rt. ft.
Geothermal(Closed loop) OTracer 20,DRILLING LOG(attach ndditfonnl sheets If necessary)
Geothermal(Heating/Cooling Return) Otlte (explain under 1i21 Remarks) FROM TO InsSCttttt tON(obit.,hardness,soil/tact+type,grain sire,ore.)
10-25-23 a rt. 50 ft' DIRT
4.Date Well(s)Completed: Well ID// 50 . ft' 445 ft. ROCK
5a.Well Location: ft. ft.
LAKEMIST HOMES ft. ft. I
i
Facility/Owner Name Facility 1D11(if applicable) ft. ft. -
148 RYLEIGH DAN,MOORESVILLE,N,C, 28115 ft. n, le,.� . n k. .;14— C 1
Physical Address,City,and Zipft. ft.IREDELL 4654-79-0061 21.REMARkS l/s'I\! 2024
County Parcel Identification No,(PIN) i In`InrS1jp17,•r..^7y :, '
5b,Latitude and longitude in degrees/minutes/seconds or decimal degrees: "'
Iowa Ot3
cif well field,one tat/long is sufficient) 22.CortifiC It: 1'
35° 31.185 N, 80° 49.519
w I,
P 10-25-23
6.1s(are)the well(s)0X Permanent or DI'I'emporary Signature of Certified Well Contractor I Date
By signing This form, 1 hereby certify That the well(s) was(were)constructed in accordance
7.Is this tl repair to an existing well: Dyes or ONo with 15A NCAC 02C.0100 et'15At NC,C 02C.0200 tt'e!/Construction Standards and that a
If this is a repair,ji!l ma karma u'e•/l construction hiJb,•n,alian and etp,ial,'the nature(lithe c'opr aP'N is record has been provlded to lheiwell owner.
repair under 112/remarks section or on the back of this flaw,. 1.
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 1 GW-1 is needed. Indicate'I'O'l'ALLAUMBER of wells construction details. You may also attach'additional pages if necessary.
drilled:
SUBMIT'l'AL INSTRUCTIONS
9.Total well depth below land surface: 445
/o,multiple wells/i.rt all depths if d/Jbrarnt(example-3�200'and 2 n ron') (ft.) 24a. For All Wells: Submit this form'within 30 days of completion of well
construction to the following: j
10,Static water level below top of casing: 50 (ft.) Division of Water Resourcess,Information Processing Unit,
If%rater level is above casing,use"+•"
6 1617 Mail Service Centcr,i Raleigh,NC 27699-1617
11,Borehole diameter: (in.) 24b, For Injection Wells: In addition)Id sending the form to the address in 24a
12.Well construction method: above, also submit one copy of this loan within 30 days of completion of well
(i.e,auger,rota construction to the following: I
ry,cable,direct push,etc,)
FOR WATER SUPPLY WELLS ONLY: of Water Resources,Underground Injection Control Program,
1636 Mail Service Centir,'Raleigh,NC 27699-1636
13a.Yield to 25 AIR
(gP ) Method of test: 24c. For Water Supply&Infection Wells: In addition to sending the form to
13b.Disinfection t e: HTH the address(es)1 above, also submit ode 'copy of this form within 30 days of,
YP Amount: completion of well construction to the,county health department of the county
where constricted.
Form OW-I - North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016