GW1-2023-00374_Well Construction - GW1_20230103

WELL CONSTRUCTION RECORD (GW 1) For internal Use Only:
I.Well Contractor Information:
RANDY OWNBEY
14.R'ATER ZONES t;
Well Contractor Name FRoat TO DESCRIPTION
3214A P57
90
ft.
NC Well Contractor Certification Number
AIR DRILLING I N C ASING(f°r°,°'ti-eas�d;ve115 OR LINER ifa licable
O DIAMETF.It TIIICKNESS MATERIAL
Company Name tt. 6 f in. PVC
330206 INNER CASING OR TUBING cothern,al closed-too
2.Well Construction Permit#: FROM TO DIAMETER TIIICKNESS N"'TERIAL
List all applicable well construction Permits(i.e.U1C County,State,iMarimhce,etc.) ft. ft. in.
3.Well Use(check well use): ft. R. in.
Water Supply Well: 17.SCREEN
FROM - •1.0 DIAMt;1'ER SLOT SV',E THICKNESS MATERIAL
❑Municipal/Public ft. tt. in.
❑Geothermal(Heating/Cooling Supply) IJRcsidential Water Supply(single) g. ft. in.
❑industrial/Conuncrcial ❑Residential Water Supply(shared) fig,GROUT
❑Irrigation ❑"IM 6 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 rt• 20 ft- GROUT POURED
❑Monitoring ❑Recovery n. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinit Barrier 19.SAND/GRAVEL PACK if a Iicablc
y FROM TO 51ATERIAL I EMPLACBMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additionat sheets if necessary)
FRUdI —TO DESCRIPTION(color,hardness,soiUrock type. rain size,etc.❑Gcothennal(Heating/Cooling Return) ❑Other(explain under 421 Remarks)
0 f` 47 f`• DIRT
4.Date Well(s)Completed: 08-31-2022 Well IDN 47 ft 805 r`• ROCK
5a.Well Location: ft. ft.
LAVERNE LOVE
'may
Facility/Owner Name Facility iDN(if applicable) ft. ft. ( ir..v=
364 INGRAM RD,STATESVILLE,N.C. 28677
Physical Address,City,and Zip ft. ft.
IREDELL 4747022649 21.REMARKS r __�_• ; >,;. : � 1
County Parcel identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IaVlong is sufficient) 22.Certif on:
35° 43.006 N 80° 29.545 Nr 8/31/2022
6.Is(are)the well(s)• InPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby cert fi,that the rvell(s)was(were)constructed im accordance with
7.Is this a repair to an existing well: ❑Ycs or InNo 15.4 NCAC 02C.0100 ar 15A NCAC 02C.0200 Well Construction Standards and that a copy
!f this is a repair•fill out knouvt well construction it foruration and explain the mature of the of this record has been provided to the well owner.
repair under N21 remrarkr section or on the back of this for•uh.
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 orwclls (add'Sce Ovice in Remarks Box).You may also attach additional pages if necessary.
drilled:
24.SUBMITTAL INSTRUCTIONS'
9.'rotal well depth below land surface: 805 ft.)ror tmulliple wells list all depths ifdierent(eromrp ale-3 200'and 2 r@i 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),
lfwater 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-'l636
1.e Well construction cable, methods 24c.For Water Supply and Open-Lotip 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(gpnt) Method of test:
AIR Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount
II
Form GWA North Carolina Department or Environmental Quality-Division of Wader Resources j Revised 6-6-2018