GW1-2022-01485_Well Construction - GW1_20220120

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor information:
1
RANDY OWNBEY
�r:
^ +�ii`� 14.WATER ZONES
Well Contractor Name .FROM TO DESCRIPTION
3214A H =�` Q �Q� 249 ft 250 ft. F
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased wells OR LINER'ifa licable
AIR DRILLING INC .,,;' 'r._„ten FROM TO DIAMETER THICKNESS MATERIAL
Company Name � i;;i'•� �•� �-'
tt g Jr ft. 6 PVC
r st v 16.INNER CASING OR TU BING: eothermal closed=loo
2.Well Construction Permit#: 310905 FROM TO I DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,Stare, Variance,etc.) rt ft. iin.
3.Well Use(check well use): rL ft.
Water Supply Well: '`1ZSCREEN
FROM TO DIAMETER ;SLOTSIZE I THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
ft. ft in.
❑Ind ustrial/Commercial ❑Residential Water Supply(shared)
18.GROUT
❑Irrigation ❑Wells>100000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 tt. GROUT POURED
❑Monitoring ❑Recovery ft. ft.
Injection Well:
❑A uifer Recharge ❑Groundwater Remediation rL ft.
❑Aquifer Storage and Recovery ❑Salinit Barrier 19•SAND/GRAVEL PACK ifa licable
Y FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test 17Stormwater Drainage ft ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets ifnecessa .
❑Gcothermal(Heating/Cooling Return) OOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.)
0 rL 75 ft. DIRT
4.Date Well(s)Completed: 10-21-21 Well ID# 75 it 265 it. ROCK
5a.Well Location: ft ft
JAMES CAMPBELL ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
169 FALLEN ACORN,TROLITMAN,N.C. 28166 ft ft.
Physical Address,City,and Zip ft. ft.
IREDELL 4761120507 '_21.REMARKS
County Parcel Identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Iat/long is sufficient) 22.Cer' tion:
350 41.390 N 800 48.532 W
10/21/2021
6.Is(are)the well(s): In Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,/hereby certify that Me well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or t9No 15A NCAC 02C.0100 or 15A NCAC 02C!02110 Well Construction Standards and that a copy
!f this is a repair,fill out known well construction information and explain the nature of die of this record has been provided to the well owner,
repair under,Y21 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-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: 265 ft.)
ror multiple wells list all depths ifdierent(example-300'and 2@100') ( Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 40 (ft) 24a. For All Wells: Original form' to Division of Water Resources (DWR),
if water level is above casing,use"+.• Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For injection Wells:Copy to 6WR,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 over 100,000 GPD- Copy to DWR,CCPCUA
13a.Yield(gpm) 8 Method of test: AIR Permit Program, 1611 MSC,Raleigh,NC 27699-1 6 1 1
13b.Disinfection type: HTH Amount:
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Form GW-I North Carolina Department of Environmental Quality-'Division of Water Resources i Revised 6-6-2018