GW1-2022-01476_Well Construction - GW1_20220120

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: }
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1.Well Contractor Information:
RANDY OWNBEY rat
-14:WATER ZONES;
Well Contractor Name �` FROM TO DESCRIPTION .
3214A 2 Q 20? 529 fL 530 It.
ft. ft.
NC Well Contractor Certification Number
t^ 45.OUTER CASING',for muiti cased wells OR LINER if a` livable 1 .AIR DRILLING INC i �t „23� ' �, O OM ft I TO 6`$ ft- s NA—METER 1n THICKNESS PVC RIAL
Company Name
16JNNER CASING'ORTUBING eothermal closed-loop)
2.Well Construction Permit#: 320949 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UiC,County,State,Variance,etc.) fL ft. in•
3.Well Use(check well use): IL ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. fa in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in•
❑Industrial/Commercial ❑Residential Water Supply(shared) 118.GROUT''
❑Irri ation OWells>100,000GPD FROM TO MATERIAL, EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 20 ft- GROUT POURED
❑Monitoring ❑Recovery fL ft.
Injection Well:
fL ft.
❑Aquifer Recharge ❑Groundwater Remediation
`19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. fa
❑Geothermal(Closed Loop) ❑Tracer 20DRILLING LOG'attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
0 ft. 58 ft- DIRT
4.Date Well(s)Completed: 11-12-2021 Well ID# 58 fa 545 ft- ROCK
5a.Well Location: ft ft.
MOOREFIELD BUILDERS fL ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
251 SUNNY PATH,STATESVILLE,N-C. 28677 ft. fL
Physical Address,City,and Zip ft. ft.
IREDELL 4710650892 2hREMARKS-
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ha/long is sufficient) 22.C e8,0 '
350 40.245 N 800 57.479 W
11/12/2021
6.Is(are)the well(s): PJPermanent or ❑Temporary Signature ofCertified Well Contractor Date
By signing this form,I hereby certify that dre wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
if this is a repair,fill out known well construction information and explain the nature of(he Pf this record has been provided to the well 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 to provide additional well construction info
construction,only 1 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: 545 (ft.) Submit this GW-1 within 30 days of well completion per the following:
ror multiple wells list all depths ifdifferent(example-3 a 00'and 1Qa 100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
f Static water level below top of casing: 50 (fG) Information Processing Unit,1617 MSC,'Raleigh,NC 27699-1617
Ijwater level is above casing,use"+" I
11.Borehole diameter: 6 (in,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24c.For Water Supely and Open-Lolop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push etc.) county environments heat department o the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
5 AIR
Permit Program,1611 MSC,Raleigh,NC 27699-1 61 1
138.Yield(gpm) Method of test:
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13b.Disinfection type: HTH Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources i Revised 6-6-2018
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