GW1-2022-01555_Well Construction - GW1_20220120

WELL CONSTRUCTION RECORD(GW-1), For Internal Use Only:
1.Well Contractor Information.
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RANDY OWNBEY I4.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
" 189 ft- 190 ft.
3214A i s-;�a °`
ft. ft I
NC Well Contractor Certification Number 15.OUTER CASING for molt*-cased wells)DR LINER if a licable
AIR DRILLING INC H t�Z�; FROM TO DIA1.1ETER THICKNESS MATERIAL
�oCe� 0 ft- 146 ft. 16 in. IPVC
Company Name ° ,i�: "1 t
f L �'`�'��J Oil 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: 318694 FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable+cell 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 SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ClResidential Water Supply(single) fr. ft in,
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri atlon ❑Wells>100,000GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fa 20 rt• GROUT POURED
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ro 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,soi0rack type,grain size,etc.
0 fL 36 1- DIRT
4.Date Well(s)Completed: 10-13-2021 Well ID# 36 fL 205 ft- ROCK
Sa.Well Location: ft ft.
JOE JOSEY ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
425 PISGAH RIDGE CL, HIDDENITE,N.C. 28636 ft e.
Physical Address,City,and Zip
ft. ft.
IREDELL 4709984057 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one IatAong is sufficient) 22. Ieatio .
350 55.355 N 800 59.419 W
10/13/2021
6.Is(are)the well(s): [!]Permanent or ❑Temporary Signature o Certified Well Contractor Date
Hy signing this.fornu,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or [!]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 explain the nature of the of this record has been provided t,the well,owner.
repair under 1l21 remarks section or on the hack of dtis 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: 205 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if dierent(eranple-3@200'and 2@100')
10. 50 24a. For All Wells: Original form to Division of Water Resources (DWR),
fwafer level is shove casing,use Static water level below top of casing: (ft) Information Processing Unit, 1617 MSC;Raleigh,NC 27699-1617
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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) 40 Method of test: AIR
Permit Program,1611 MSC,Raleigh,NC 27699-16 1 1
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13b.Disinfection type: HTH Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources I Revised 6-6-2018
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