GW1-2022-01480_Well Construction - GW1_20220120

WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only:
I.Well Contractor Information: i
RANDY OWNBEY
ti v M WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3214A 20 20?i 509 re 510 ft.
ft. ft.
NC Well Contractor Certification Number r rl 1 1 Z l3 ;
AIR DRILLING INC i`+ yet 13.OUTERCASING(for multi-cased wells ORLINER'ifa`"licable
iy ': s? -' J t nyt FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 fL 111 ft- 6 is PVC
237265/310827 16 INNER CASING'OR"TUBING eothermal closed400
2.Well Construction Permit#. FROM I TO I DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.U1C,County,Stole,Variance,etc.) fL ft. in.
3.Well Use(check well use): fL ft. in.
Water Supply Well: 17i SCREEN
❑A CUItUfal FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Municipal/Public fL ft. in.
❑Geothermal(Heating/Cooling Supply) InResidential Water Supply(single)
ft. fL in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
18.GROUT.
❑Irri ation ❑Wells>100 LACEMENT 000 GPD FROM TO MATERIAL EMP METHOD&AMOUNT
Non-Water Supply Well: 0 fL 20 fL GROUT POURED
❑Monitoring ❑Recovery ft. ft.
Injection Well:
❑A uifer Recharge ❑Groundwater Remediation fL ft.
❑Aquifer Storage and Recovery ❑Salinity Barrier nDRJILLING
AVEL PACK(fain)"licable
TO _ MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft.
❑Experimental Technology ❑Subsidence Control ft.
❑Geothermal(Closed Loop) ❑Tracer LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#2l Remarks) To DESCRn'TION tcolor,hardness soillrock type,grains etc
0 ft- 101 fL DIRT
4.Date Well(s)Completed: 11-22-2021 Well ID# 101 fL 525 fa ROCK
Sa.Well Location: fL ft.
PEACHTREE RESIDENTIAL fL IL
Facility/Owner Name Facility IDk(ifapplicable) fL ft.
120 BROAD BIRCH DR,DAVIDSON,N.C. 28036 fL fL
Physical Address,City,and Zip ft. ft.
I REDELL 4664865721 121.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Cer• ation-
35° 30.507 N 80° 47.978 W
11/22/2021
6.Is(are)the well(s): InPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or InN0 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a copy
lfthis 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 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-I 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: 525 (fL)
For multiple wells list all depths ljdoerent(example-3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
I
10.Static water level below top of casing: 60 (ft) 24a. For All Wells: Original form Ito Division of Water Resources (DWR),
If water level is above casing,use"+^ Information Processing Unit,1617 MSC;Raleigh,NC 27699-1617
i
11.Borehole diameter: 6 (in.) 24b.For Injection Wells:Copy to DWR Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
.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 epartment o e county wherein stal
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD•Copy to DWR,CCPCUA
13a.Yield(gpm) 10 Method of test: AIR Permit Program,1611 MSC,Raleigh,NC 276994611
13b.Disinfection type: HTH Amount:
1
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018