GW1-2022-01501_Well Construction - GW1_20220120

i
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: j
1.Well Contractor Information: ^' #
RANDY OWNBEY �' 4';w ,�i+� 1
°" � §" 14 WATER ZONES
Well Contractor Name —FROM TO I DESCRIPTION
ft ft. I
3214A ,�� 2 Q ,,, 689 670
n i t>>'
NC Well Contractor Certification Number
0 15.OUTER CASING for multi-cased wells OR LINER if a licable
AIR DRILLING INC �j;'-}cf �� �J„ FROM 1'O DIAMETER; THICKNESS MATERIAL
Company Name 0 f`' 64 ft' 6
236367/311335 16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#. FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C;County,State, Variance,etc.) fL ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO I DIAMETER 11 SLOTSIZE I THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.,
❑Geothermal(Heating/Cooling Supply) CnResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METIIOD&AMOUNT
Non-Water Supply Well: 0 fr• 20 ft- GROUT POURED
❑Monitoring 0Recovery ft. ft.
Injection Well;
ft.
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier 19.SAND/GRAVEL'PAC K ifalicableFROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test OStormwater Drainage fr. R.
❑Experimental Technology CiSubsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING'LOG attach additions lsheets if necessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain size etc.
0 ft. 54 ft. DIRT
4.Date Well(s)Completed: 10-11-2021 Well ID# 54 ft- 705 ft- ROCK j
5a.Well Location: fL ft.
OAK HILL HOMES ft ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
104 BROAD BIRCH DR,DAVIDSON,N.C. 28036 ft. ft.
Physical Address,City,and Zip ft. ft.
IREDELL 4664872150 121.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iattlong is sufficient) 22.Cer ation•
35a 30.533 N 800 47.113 W 10/11/2021
6.Is(are)the well(s): [!]Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)consir cted in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo I5A NCAC 02C.0100 or 15A NCAC 02C i0200 Well Construction Standards and that a copy
If this is a repair,_fll out known well construction information and explain the native 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-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: 705 fL
for multiple wells list all depths tjdierent(example-3 rJ 00'otd 1@a 100') ( ) Submit this GW-1 within 30 days of well completion per the fallowing:
10.Static hater level.below top of casing: 60 24a. For All Wells: Original form to Division of Water Resources (DWR),
1f 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 DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24c.For Water Supply and Open-Loon 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
10 AIR Permit Program,1611 MSC,Raleigh,,NC 27699-1611
13a.Yield(gpm) Method of test:
k ;
13b.Disinfection type: HTH Amount:
6
r
Forst GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
i