GW1-2022-01500_Well Construction - GW1_20220120

WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only:
1.Well Contractor Information:
RANDY OWNBEY s�
• '" ?"$'a^� �,S 14.WATER ZONES
Well Contractor Name y`�»"' el FROM TO DESCRIPTION
3214A 0 r�� A, 509 fL 510 ft.
,a 10 • fL I
NC Well Contractor Certification Number '' r y f`tn7 .;s' ft
15.OUTER CASING for multi cased wells OR LINER if a licable
AIR DRILLING INC - '' ` r''s�� FROM TO DIAMETER THICKNESS MATERIAL
Company Name t• �l `, 0 ft. 57 ft. 6 'in, PVC
302284 16.INNER CASING OR TUBING eothermat closed-loop)
2.Well Construction Permit#. FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permtls(i.e.VIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft.
Water Supply Well: 17.SCREEN
EFRTO DIAMETER SLOTSIZE THICKNESS MATERIAL
OAgricultural ❑Municipal/Public ft. in.
❑Geothermal(Heating/Cooling Supply) InResidential Water Supply(single)
fL in.
❑Industrial/Commercial ❑Residential WaterSupply(shared) T❑Irri ation ❑Wells>100,000GPD TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fr. 20 ft. GROUT POURED
❑Monitoring ❑Recovery fL ft.
Injection Well:
ft. f.❑A uifer Recharge ❑Groundwater Remediation❑Aquifer Storage and Recovery OSalinit Barrier I9•SAND/GRAVEL PACK ifa licable
y FROM I TO I MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑StormwaterDrainage fL ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness,soRfrock type,erain size,etc.
0 ft. 47 ft. DIRT
4.Date Well(s)Completed: 10-5-2021 Well ID# 47 ft- 525 ft- ROCK
5a.Well Location: ft. ft.
BRUCE.DECARON ft. ft.
Facility/Owner Name Facility lD#(ifapplicable) ft. ft.
146 BROAD BIRCH DR,DAVIDSON,N.C.'28036 ft. ft.
Physical Address,City,and Zip ft. ft.
IREDELL 4664951083 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifivell field,one latAong is sufficient) 22.Certif
350 30.468 N 800 47.445 W
10/5/2021
6.Is(are)the well(s): ItPermanent or ❑Temporary Signature ofCert rcd Well Contractor Date
By signing this form,/hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: OYes or InNo ISA NC'AC 02C.0100 or 15A NCAC 02C.b200 Well Construction Standards and that a copy
/f li i.s is a repair,fr//our known well cons/ruction 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 Gcoprobe/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 tray also attach additional pages if necessary.
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 525 -(ft)
For multiple sve/is list all depths jd!(jerent(eroinple-3@200'and 2Q100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 60 ft 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwater level is above casing,use +" (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
In
jection'
11.Borehole diameter: 6 (in,) 24b. Wells: Copy to DWR, Underground Injection Control(!UC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: I
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 o the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing ovel 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 20 Method of test: AIR Permit Program, 1611 MSC,Raleigh,kC 27699-161 1
13b.Disinfection type: HTH Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018