GW1-2022-01536_Well Construction - GW1_20220120

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: I
RANDY OWENBY ;� WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
h 809 ft- 810 ft.
3214A -,>v e�� „> ft. fL
NC Well Contractor Certification Number 8.�9 ©� 15.OUTER CASING for multi�ased wells OR LINER if a licable
AIR DRILLING A `;� Cd7l FROM ft TO ft DIAMETER n THICKNESS MATERIAL
Company Name 0 57 6 PVC
c' 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: 237263 `� FROM TO DIAMETER! THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,Cgitn'o,'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 ❑MunicipaUPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) [!]Residential Water Supply(single) ft. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL, EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fc 20 ft- GROUT POURED
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft. �
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. fL
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/racktype, rain sae,etc
0 ft 57 ft• DIRT
4.Date Well(s)Completed: 2-23-2021 Well ID# 57 It. 825 rt. ROCK
5a.Well Location: ft ft.
PEACHTREE RESIDENTIAL ft ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
116 BROAD BIRCH DR,DAVIDSON,N.C. 28036 ft ft
Physical Address,City,and Zip ft. ft.
IREDELL 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.Ce on:
350 30.511 N 800 47.100 W
2/23/2021
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the'wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or In No 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 erplain 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 1 GWA 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: 825 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths tfdierent(example-3[d 00'and 2@100')
10.Static water level below top of casing: 50 (ft) 24a. For All Wells: Original form Ito Division of Water Resources (DWR),
if 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-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) 8 Method of test- AIR Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount:
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources I Revised 6-6-2018