GW1-2022-01478_Well Construction - GW1_20220120

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: j
1.Well Contractor Information:
RANDY OWNBEY c."N tld
14.WATER ZONES
?
Well Contractor Name FROM TO DESCRIPTION 3214A 229 ft- 230 ft-
ft.2
rt;^ ft. ft.
NC Well Contractor Certification Number ti•r+ ,
t 15.OUTER CASING'for mold cased wells OR LINER if a 'lleatile _--._
AIR DRILLING INC Iu:ems`'� L�V "O� FROM TO DIAMETER THICKNESS MATERIAL
0 ft 54 ft• 6 PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loo.
2.Well Construction Permit#: 240877 FROM TO I DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC.County,State, Variance,etc.) ft ft. in.
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipat/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) CiResidential Water Supply(single) ft. ft
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lrri ation ❑WellS>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft. GROUT POURED
❑Monitoring ORecovery ft ft.
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage r. I
❑Experimental Technology ❑Subsidence Control ft. I ft.
DGeothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additionalfsheets'ifnecessa
DGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hnrdne soiurock a rain AM etc.
0 ft 40 fi- DIRT
4.Date Well(s)Completed: 11-15-2021 Well ID# 40 ft. 245 ft- ROCK
ft ft.
Sa.Well Location:
OAK HILL HOMES ft ft
Facility/Owner Name Facility ID#(if applicable) ft ft.
195 LOGAN CROSSING,DAVIDSON,N.C. 28036 ft ft.
Physical Address,City,and Zip ft ft.
IREDELL 4664569784 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iatlong is sufficient) 22.Certi on:
35e 30.485 N 800 47.417 W
11/15/2021
6.Is(are)the well(s): OPermanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 01C.0100 or 15A NCAC 02C.b200 Well Construction Standards and that a copy
/fthis is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under 921 remarks section or on the back of this farm.
23.Site diagram or additional well details:
8.For GeoprobetOPT 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: 245 (ft) Submit this GW-1 within 30 days of well completion per the following:
!br multiple wells list all depths if different(example-3 rer 200'and 2@100')
10.Static water level below top of casing: 50 (ft) 24s. For All Wells: Original form;to Division of Water Resources (DWR),
lfwaler level is above casing,use^+^ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
6 24b.For Injection Wells:Copy to DWR, Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program,1636 MSC;Raleigh,NC 27699-1636
12.Well construction method: 24c.For Water Supply and Open-Lo'oo Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county-environmental heal department of the county where instal
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing overl100,000 GPD:Copy to DWR,CCPCUA
13a.Yield( pm) 25 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