GW1-2022-01444_Well Construction - GW1_20220120

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: k
1.Well Contractor Information:
RANDY OWNBEY '�
14.WATER ZONES '
Well Contractor Name ;} "- n FROM TO DESCRIPTION
3214A 2 © 20?` 289 rt 290 ft-
NC Well Contractor Certification Number �� F
t`'•�" IS OUTER CASING ffor multi-cased"wells OR LiNER ifa licable
AIR DRILLING INC , ;, - ^'' `�'� FROM TO DIAMETER' THICKNESS MATERIAL
Company Name 0 rL 85 ft. 6 7n. GALV
07-2021-154867 16.INNER CASING OR TUBING eothermal closed-loon)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well ionsiniclion permits(i.e.111C,County,Stale,Variance,etc.) fL ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17;SCREEN
FROM - TO DIAMETER SLOTSIZE I THICKNESS MATERIAL
❑Agricultural CMunicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) In Residential Water Supply(single) ft. ft. in.
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑bTi ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft- GROUT POURED
❑Monitoring ❑Recovery ft. ft.
injection Well:
[]Aquifer Recharge ❑Groundwater Remediation ft. ft.
19.SAND/GRAVEL PACK ifa licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control fL ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soillrock type,grain sae,etc.
0 fQ 75 fL DIRT
4.Date Well(s)Completed: 9-13-2021 Well ID# 75 ft- 305 ft. ROCK
5a.Well Location: ft. ft.
JONATHAN SCRONCE R. ft.
Facility/Owner Name Facility IDft(ifapplicable) ft. ft.
6085 REDEMPTION TRAIL,CONOVER,N.C. 28613 ft. ft.
Physical Address,City,mid Zip ft. ft.
CATAWBA 374516840582 21.REMARKS
County Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one ladlong is sufficient) 22.Certi ation:
35a 48.128 N 81011.566 W 9/13/2021
6.ls(ere)the well(S): dPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this fonn,I hereby certify that the well(s)was(were)constructed in accordance with
7.is this a repair to an existing well: ❑Yes or 8No 15A NCAC 02C.0/00 or 15A NCAC 01C:0100 Well Consruclion Standards and that a copy
if this is a repair,fill oul known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under fill remarks section or on the hack 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 to provide additional well construction info
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 305 (ft)
For nwhiple wells list all depths ifdtTerent(example-r @200'and 2 a 100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 40 (ft)
249. For All Wells: Original form to Division of Water Resources (DWR),
/fwaier love/is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells:Copy to MR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
i..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 over100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm)
10 Method of test: AIR Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount:
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018