GW1-2022-01577_Well Construction - GW1_20220120

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: f°
RANDY OWNBEY 'l14. ER ZONES
FROM
Well Contractor Name FROM TO DESCRIPTION
189 fc 190 ft.
3214A P� °-,o^ ft. ft.
NC Well Contractor Certification Number
r;•.` 15.OUTER CASING for multi-cased wells{OR LINER if a licable
AIR DRILLING INC FROM TO DIAMETER THICKNESS MATERIAL
0 ft- 1103 ft- 16 i" PVC
Company Name \:
16.INNER CASING OR TUBING(geothermal closed-too
2.Well Construction Permit#: 355312 FROM TO DIAMETER 1 THICKNESS MATERIAL
List all applicable well construction permits(i.e.U/C,County,State, Variance,etc.) ft. ft. in,
3.Well Use(check well use): ft. ft. in,
17.SCREEN
Water Supply Well:
_ FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. R. in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
[Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl atlon ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fc 20 fi- 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 TO MATERIAL I 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 Fcolor,hardness,soil/mck type,grain size,etc.
0 ft- 103 ft- DIRT
4.Date Well(s)Completed: 4-15-2021 Well ID# 103 ft- 205 ft- ROCK
5a.Well Location: Ft. R.
HUGH STOCUM fr. ft.
Facility/owner Name Facility ID#(ifapplicable) ft. ft.
1080 FLASH BULLET DR, ROCKWELL,N.C.28138 ft. ft.
Physical Address,City,and Zip ft. ft.
ROWAN 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one]at/long is sufficient) 22,Certifi 1:
350 33.242 N 800 29.501 W
4/15/2021
6.Is(are)the well(s): nPermanent or ❑Temporary Signature ofCenKed well Contractor Date
By signing this form,l hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or InNo 15,4 NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a copy
lfthis is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well awner.
repair under=21 remarks section or on the back of this farm.
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 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)
For multiple wells list a//depths ifdfferent(example-3@200'and 2@/00') Submit this GW-1 within 30 days of well completion per the following:
40 24a. For All Wells: Original forth to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft) Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
Ifwaier 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
12.Well construction method: 24c.For Water Supply and Open-Lo6p Geothermal Return Wells:Copy to the
(i.e.queer,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(gP m) 15 Method of test- AIR Permit Program,1611 MSC,Raleigh,NC 27699-1611
I
13b.Disinfection type: HTH Amount:
Form GW-1 - North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018