GW1-2022-01522_Well Construction - GW1_20220120

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
RANDY OWNBY
14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 689 ft 690 ft-
3214A CV
ft. f,
NC Well Contractor Certification Number PC Fj15.OUTER CASING�fcas wells)OR-LINER`(if.#Jie.ble)°�---�7
AIR DRILLING INC FROM I TO I DIAMETER THICKNESS MATERIAL
6 0 ft. 100 ft. 16 i in.
Company Name
238921 16.114NERCASING"..-OR-T BU4G`(ge6theiiiig�ibi�ed4br6i)),,'
2.Well Construction Permit#: FROM TO DIAMETER. THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,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 SUE THICKNESS MATERIAL
OAgricultural EDMunicipat/Public ft. fL in.
DGeothermal(Heating/Cooling Supply) InResidential Water Supply(single) -ft. ft. in.
01ndustriall'Commercial OResidentW Water Supply(shared) 18.GROUT
0hrigation OWells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft20 ft GROUT POURED
OM[onitoring ORecovery ft. ft.
Injection Well: ft. ft.
OAquifer Recharge OGroundwater Remediation SAN DGRAVEL'PACK,(if j1ppficible)
DAquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
0Aquifer Test OStormwater Drainage ft. ft.
OExperimental Technology OSubsidence Control ft. ft.
DGeothermal(Closed Loop) OTracer 20.DRILLING,LOG'(iittkch:addidonil:shieti�,,if-.Wiicessit;y),,'
OGeothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM I TO DESCRIPTION(color,hardness,soittrock ryM grain size,etc.)
0 ft go ft- DIRT
4.Date Well(s)Completed: 3-4-2021 Well ID# 90 fL 705 ft ROCK
.
5a.Well Location: ft ft.
PEACHTREE RESIDENTIAL ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft ft.
144 WALKING HORSE TRAIL, DAVIDSONAC. 28036 ft ft.
Physical Address,City,and Zip fL ft
IREDELL 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 on:
35030.550 N 80047.182 W 3/4/2021
A.Is(are)the well(s): [nPermanent or OTemporary 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: DYes or InNo 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 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-I is needed. Indicate TOTAL NUMBER of'wells (add'See Ovee in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 705 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths i(different(example-3@200'and 2@100')
10.Static water level below top of casing: 60 24a. For All Wells: Original form to Division of Water Resources (DWR),
(ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" I
11.Borehole diameter: 6 (in.) 24b.For Injection Wells:Copy toy DWR,Underground Injection Control(fUC)
Program,1636 MSC,Raleigh,NC 27699-1636
1
12.Well construction method: 24c.For Water Supply and Open-L' oop Geothermal Return ells*Copy to the
county
I
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the coun 7 where m-7t7a d
FOR WATER SUPPLY WELLS ONLY: i
24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
139.Yield(gpm) 10 Method of test- AIR Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources j Revised 6-6-20 18