GW1--00742_Well Construction - GW1_20240119

WELL CONS I RUCTION RECORD ' I Print Form
(GW-1) For Internal Use Only:
1.Well Contractor Information: 1
•
RANDY OWNBEY i I
14.WATER ZONES I
Well Contractor Name FROM TO DESCRIPTION
3214A 229 II. 230 ft• I — --
NC Well Contractor Certification Number ft. ft. I --"
i I
AIR DRILLING INC 15.OUTER CASING(for multi-cased wills)OR LINER(if•ap liable)
FROM TO DIAMETER THICKNESS MATERIAI,
Company Name 0 ft. 80 ft. 6 I in. PVC
2023-39214 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER 1 THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Slate,Variance,etc.) ft. ft. P inn.
3.Well Use(check well use): ft. ft. ' •in.
Water Supply Well: 17.SCREEN I
1FROM '1'0 DIAMETER, SLOT'SIZE THICKNESS MA'rt:RIA,_
OMunicipal/Public ft.
ft.
ft. lit.
Geothermal(Heating/Cooling Supply) EiResidenlial Water Supply(single) —
ft. in,
IndustriaUConunercial Residential Water Supply(shared)
IS,GROUT
Irrigation FROM To MATERIALEstpt.ACEMEN'rsli ritoo C A190UN'f
Non-Water Supply Well: 0 ft. 20 It, GROUT POURED
Monitoring 0 Recovery ft. It.
Injection Well:
ft. rt.Aquifer Recharge DGroundwatcr Rcmediation .
IAc niter Storageand Recovery19.SAND/GRAVEL l'ACK(if applicable)
1 OSalinityBarrier FROM TO MATERIAL EMPLACEMENT METIIOD
Aquifer Test11
�Slonnwalcr Drainage ft. R.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) DITracer 20,DRILLING LOG(attach additional sheets If necessary)
Geothermal(Heating/Cooling Return) O(her(explain under#21 Remarks) Iano�1 r0 0 rt. 70 '' D DESCR1 i'•ION'(color,hardness,soil/rocktype,train size.etc.)
;IRT'
4.Date Well(s)Completed: 12-18-23 Well ID// 70 ft. 245 ft. ROCK
5a.Well Location: ft. it. u'3? ±2 a
AMY HUTCHENSON rt. ft. N — �s 3„..,
Facility/OwnerNamc Facility IOU(if-applicable) ft. ft. Jfi 1 .2024
2821 MEADOWLARK DR,STATESVILLE,N.C. 28677 ft. ft. f —}y
ITt9 i•)rr�CC:l E l. r'•rn,',...wL:5 ViY,1
ft. rt. •Physical Address,City,and Zip ! DtvoieoG
IRED ELL 4724546524 21.REMARKS
County Parcel Identification No.(PIN)
----__.___..
Sb.Latitude and longitude in dcgrceshttinutcs/seconds or decimal degrees:
(if well field,one lid/long is sufficient) 22.Cer cantor'
35°46.822 N 800 56.187
W i12-18-23
ft.ls(nre)the well(s)JPermanent or I:Jrrcmporary Signature of Certified Well Contractor Date
Up signing this foam,1 hereby certify that the well(%)wax(wm•e)constructed in accordance
7.Is this a repair to an existing well: DYes or ONo with ISA NC/IC 02C.0100 or Mt NC/IC 02C.0200 Well Construction Standards and that a
If•this is a repair,Jill out known tool(construction it f,rarulion and explain the nohow of the Copy of this record has bee"provided to the!veil o»vner•
repair under 01 remarks section or on the back aphis firm.
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the saute You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
"-- — SUBMIT'l'AI,INSTRUCTIONS
9.Total well depth below hind surface: 245 i
For multiple wells list all depths ifd JereW(example-.t ar,200'any!2 a/00') (ft.) 24 , For All Wells: Submit this form within 30 days of completion of well
construction to the following: i
10,Static water level below top of casing: 50 (ft.) Division of Water Resource's,Information Processing Unit,
11'water level it ahoyc casing,use"+" 1617 Mail Service Centdr,jRaleigh,NC 27699-I617
6
11,Borehole diameter: (in.) 24h. For Injection Wells: In addition.to,sending the form to the address in 24a
12.Well construction method: above, also submit one copy of this form within 30 days 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
I3a.Yield(gprn) 12 Alethod of test: AIR 24c. For Water Supply& Injection Wells: In addition to sending the Ibrnt to
the address(cs) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: completion of well construction to the c lunty health department of the county
where constructed,
Form O W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-201 G
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