GW1-2022-01510_Well Construction - GW1_20220120

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
RANDY OWNBEY 14.WATER ZONES
Well Contractor Name ¢`� T.a� FROM TO DESCRIPTION
3214A 289 IL 290 fL
' ^ IL ft.
NC Well Contractor Certification Number 15,OUTER CASING for multi cased'wells OR LINER if a licable
AIR DRILLING INC rUay.�jlf� FROM TO DIAMETER THICKNESS MATERIAL
00 0 ft 82 ft. 6 in. PVC
Company Name 31
C ,.�'`
r , � .^� 16.INNER CASING OR T[JBING(geothermal closed-loop)
2.Well Construction Permit#: AP-30513`I2 10M� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State, Variance,etc) ft. ft. in.
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) In Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft. GROUT POURED
❑Monitoring ❑Recovery• fL ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(ifapplicable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage, 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,soiUrock type,grain sae,etc.
0 fL 40 ft. DIRT
4.Date Well(s)Completed: 07-27-2021 Well ID# 40 ft. 305 fl- ROCK
5a.Well Location: ft. ft.
CORNERSTONE III PROPERTIES fL ft.
Facility/Owner Name Facility iD'd(ifappticable) ft. ft.
126 TALLEY RD,TROUTMAN,N.C. 28166 ft. ft.
Physical Address,City,and Zip fL ft.
IREDELL 4731223723 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.C¢r iCatiO
350 41.361 N 800 54.431 W
7/27/2021
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MN0 15A.NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this 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-21 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: 305 (ft.) Submit this GW-1 within 30 days of! ell completion per the following:
for multiple wells list all depths if different(example-3 a 00'and 2@100')
�50 24a. For All Wells: Original form i to Division of Water Resources (DWR),
ff Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,,Raleigh,NC 27699-1617
!f water level is above casing,use
11.Borehole diameter: 6 (in.) 24b.For Injection Wells:Copy to DWR, Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 276f99-1636
12.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) 10 Method of test: AIR Penn it Program, 1611 MSC,Raleigh,NC 27699-161 1
13b.Disinfection type: HTH Amount:
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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