GW1-2022-01443_Well Construction - GW1_20220120

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
RANDY OWN BEY 4 as I4.WATER ZONES
Well Contractor Name A " FROM I TO I DESCRIPTION
3214A ` �F 2 © 20 189 ft• 190 ft.
f. ft. f
NC Well Contractor Certification Number }
15.OUTER CASING for multi-cased
'wells OR LINER ifa licable
AIR DRILLING INC '''µ�, Q
�-.ate+• 1' FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 f° 87 ft. 6 '" GALV
1 O-ZOZO-139752 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable ivell construction permits(i.e.UIC,County,Store,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. fL in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) MResidential Water Supply(single) ft. ft
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Uri ation ❑Wells> 100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft- GROUT, POURED
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hnnlness soillrock type,gnin sin.etc.
0 rc. 87 ft. DIRT
4.Date Well(s)Completed: 9-10-2021 Well ID# 87 ft• 205 ft. ROCK
Sa.Well Location:
ft. ft.
ELITE BUILDERS ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft
3958 CEDAR WOOD TRAIL,TERRELL,N.C. 28682 rt. ft.
Physical Address,City,and Zip ft. fL
CATAWBA 461704734235 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iattlong is sufficient) 22.Cer' ion:
35a 35.399 N 800 57.341 WV6
Ct .
6.Is(are)the well(s): l'JPermanent or ❑Temporary Signature ofC ified Well Contractor Date
Bysigning this forut,l hereby certify that the well(r)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or IlNo 15A NCAC 01C.0100 or 15A NCAC.'02C.0200 Well Construction.Standards and than a copy
If this is a repair,fill out known well construction h forntalon and explain the nature of the of this record has been provided to the we'll owner.
repair under 421 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page zto provide additional well construction info
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells (add'Sce Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 205 (ft•) Submit this GW1 within 30 days of well completion tltc following:
l-'or muhiple wells list all depths if different(example-3Ca 200'and 1Q100') um s - w n a Y P per b:
20 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
1f water level is above casing,use"i"
11.Borehole diameter: 6 (in,) 24b. For Injection Wells: Copy toIDWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) 20 Method or test: AIR
Permit Program,1611 MSC,Raleigh,NC 27699-16 1 1
13b.Disinfection type: HTH Amount: f
Font GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018