GW1-2022-01519_Well Construction - GW1_20220120

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: I'
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1.Well Contractor Information:
RANDY OWNBEY 14.WATER ZONES
Well Contactor Name G"'° v ^� FROM TO DESCRIPTION
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3214A a b ^ 505 fL 506 ft f
n 2 ft. ft. !
NC Well Contractor Certification Number A�! OUTER CASING for multi-cased we11s OR LINER if a licable
AIR DRILLING INC nr�r;i -�,t. `FROM TO DIAMETER' THICKNESS M1fATERtAL
��L�.,,:, 0 ft 73 It. 6 in. PVC
Company Name i,.� �j�; ''` 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: 305535 FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) fL ft. in.
3.Well Use(check well use): fr. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ItResidential Water Supply(single) ft. ft. in.
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 1`- GROUT POURED
❑Monitoring ❑Recovery ft. ft.
injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicabl e .
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL' EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. 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,sail/rock type,grain size,etc.
0 ft- 63 ft- DIRT
4.Date Well(s)Completed: 6-24-2021 Well ID# 63 fL 525 ft- ROCK
5a.Well Location: fL ft.
SPIVEY CONSTRUCTION ft. ft
Facility/Owner Name Facility iD#(if applicable) ft. ft.
124 PINE MEADOW LANE, MOORESVILLE,N.C. 28117 ft ft
Physical Address,City,and Zip ft. ft.
IREDELL 4636052813 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.Certi ation:
350 33.518 N 800 54.590 W
6/25/2021
6.Is(are)the well(s): MPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,i hereby certify that the well(s)was(were)constructed in accordance with
7.is this a repair to an existing well: ❑Yes or InNo 15A NCAC 01C.0100 or ISA NCAC 02C.0,200 Well Construction Standards and that a copy
If this is a repair,full out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair underr.'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-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: 525 (ft)
For multiple wells list all depths if different(example-3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 50 (ft) 24a. For All Wells: Original form 'to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If 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 27699=1636
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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) Method of test:12 AI R Permit Program, 1611 MSC,Raleigh,NC.27699-1611
13b.Disinfection type: HTH Amount:
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Form G W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018