GW1--00732_Well Construction - GW1_20240119

WI;LI,CONS'I'RUC'I'ION RECORD (C,VV-1
For Internal Use Only: I iI.Well Contractor Information:
RANDY OWNBEY
I �
\V• 14,WATER ZONES l
Well Collimator 1 iine _mom ` To" DI:SCIIJ'FIQN ------
3214A 229 It 230 -n• _- -- -
NC Well Contractor Certification Niunher ft• ft. ----1AIR DRILLING I N C IS.OUTER CASING(for multi-cased OR LINER(if applicable)
Alto\I__- To DIAMETER I THICKNESS _MATERIAL
c-oniinyN:une p It4n- 1't. 6 t,. PVC
16i.INNER CASING OR TUBING
-
2,Well Construction Permit 11: O,ER I___ closed-loop)
-_I
rac�aC �'t)' DIAMETER i nnr.I:Ntas tt:rrtattAl.List all all applir•ol+lr n•rN construction pc•ruut.r(i.e.(l/C.',Camay.S'trrte, hia•tarrrr,vlc•.) - -- -- ' -'- _-_I-._ __ .--- - _ ._. --
� II. fl. } iit. I
- -:3,Well Ilse(check well use): tin. 1
_
\Valor Supply Well: 17.SCREEN ( ---� --
i`irl;I'IUllhlll':11 I ITAL.__n. •IC)`•,- itiw mti'rigt• SLUT Sl E Tnickxy,_8s \iA 1.8tiA�.-I
t L1Municipal/Public - - ft. . -_.._
1 IGeothernutl(Beating/Cooling Supply) 1.11Residential Water Supply(single) --_ - - -- ---.----. ...-----_.
fl. ft. in. I 1 Ilndustr'ial/Commercial OResidential Water Supply(shared) _
18.GROUT -----
I:Ir'rigation ClWells> 100,000CPO FR0Mt To MATERIAL ' EMPLACEMENT ME'rnoo,:AMOUNT
Non-Water Supply Well: 0 n, 20 ft. GROUT POURED
fJl\9onito'ing IJRecovery rt. ft. i
Injection Well•
I.!Aquifer I. -
1 Recharge ['Groundwater Remediation IL - n I,
Clr\yuilcr Sloragc and Recover, 19.SAND/GRAVEL PACT((if:tpplicnble)
❑Salinity 13arr'ier _r ansi To - MATERIAL It'II l.r\c1_.ul•:a r.NI•:nll)D '---!
!Aquifer lest - 1.1Stormwaler Drainage I'I. ft 1
!I?xperintentll'I'eehnolo+ El. - -- - ' -- •----.._. ._. ._
Technology �a Subsidence Control ft. rt.
! C ieutherrnal(Closed Loop) II1racor
20.llRILLINC,LOG (notch additional sheets if necessary) -------
! 1(icothcrrt ll(I(eating/Cooling Return) LlOther(explain under/l21 Remarks) raq�C -_EL_____ 9t?SC1tn rtt>N_(color.�,,,ryl trss. lr,o.r,iy.ie,•ra„si.,, n•.>
0 rt. 30 rL DIRT
05-18-2023
4.Date Well(s)Completed: • Well 1D// 30 it 245 Il• ROCK '.
5a.Well Location; rt. IL
- - --
SOUTHERN DISTILLING ft. ft--_ -- "-
fl, I__._ .-_-_-__-- -- •-_-- I, �,
^.-.•• t�ff ; S yit t. - - . • : fa�Facilityrfrener Name Facility ID/1(if applicable)211 JENNING RD,STATESVILLE,N.C. 28625 ___fl 11. i' _`-_ - - _ -JgJ1j 1
1.
Physical Address,City,and Zip )l, ft. LVZ¢
21.REIUARKS ''~4r4:2rt f-h-r.,.� -�
County t-1'L-e•r,..Lp,�. .�.i?
Parcel Identification No.(PIN) -',-•
5b.Latitude and longitude in degrees/minutes/seconds ordecimal degrees:
- - - -- -
or won field,one lar/long is sufficient) 22.Cet'tifi n: _ ---- - -
35° 51.537 N 80° 51 .611 ��
\' I 5/18/2023
Cc.Is(;u•e)the svell(s): OPermnnent or C1Temporary Signature ofCei1i ied Well Contractor Date -_._...
By signing this,/arm,l hereby Gut*.that the ire./I(s)was(were)constructed in,n•rr.rdunce with
7.Is this a repair to an existing well: f.iYes or ['no 154 r\tC:•IC'02C'.0100 or/5.I NC:•I('(1.?(:.02'lt0 Well C'ousrrurliun S7audurdv and that u,op,
Olds is a rcpu/r.•/ill out known,Pell cons/me/ionIn/(lt•ntalion and explain the nature o/'the ' O/'Ihis i'm'o,sl Ins hem/lroridcd in the well wine',
npalr under 11:21 renucc'kr section or an the hack gratis firs. , I I
23.Site diagram am-additional well details: I
' 8.For Geoprabc/OPT or Close(\-Loop Geothermal Wells having the same You may use the burl: ol'this page w'provide tttlditiunal well construction in li
Construction,only I OW-1 is needed. Indicate TOTAL NUMBER of wells (add'Sec Over'in Remarks 13ox).You May also attach additional pages if necessary.
drilled:
• 24.SUI3MIT'I'Al;INSTRUCTIONS
9.Total well depth below land surface: 245 (1.i•)
Submit this Gw-1 within 30(lays of well Co nipIclion per the I'ollowieg:
Pot.nwhip(r Irv&list an dept/tr i/ditkrew lecuntple..3:!1?20)'uum/20)l a(1')
Ill Static wafer level below top of casing; 20 fl, 24a. hot All Wells; Original Porn to Division ul' Water Rcsutu'ces ll)WRi.
if water level is above easing,use"+" ( ) lnlbrmaliort Processing Unit, IG 17 MSC::,Raleigh,NC 27699-I617
I1.13orchUledian)cler: 6 (in,) 24b. For injection Wells: Copy to DWIR. Underground Injection Control (Rif')
Program, 1636 MSC,Raleigh,NC 27699-1636 I
12.auger,
construction method: ) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
nul;(i.e. er,rotary,cable,direct tsh,eta county envii'outrlenlal health clepannient.o the county where installed
FOR wATER SUPPLY WELLS ONLY: I '
24d.For Water Wells producing over.100,000 GPI): Copy to DWR.CCPCUA
13a.Yield(gpm) 5 Method of test:AIR Permit Program, ICil I MSC,Raleigh,NC'27699-I6I 1
13b.Disinfection type: HTH Amount:
I, I
Party(IN'-I North Carolina Department orEnvironrnenad Quality-Division or Water Resources li +
i Resiced 6-0:!(11 X
b •
f 1