GW1-2023-00376_Well Construction - GW1_20230103

WELL CONSTRUCTION RECORD (GW 1) For Internal Use Only:
I.Well Contractor Information:
RANDY OWNBEY •14.WATER ZONES
Well Contractor Name FROM 't•O DESCRIPTION
3214A 549 ft 550 rut. �yy
Ct. ft• i
NC Well Contractor CcrliOcalion Number
AIR DRILLING I N C 15,OUTER-CASING(for multi-cased swells)OR LINER(if a liable
FRO\I TO DIAMETER T111CKNESS 5ATERIAL
Company Name 0 ft• 51 ft' 6 i" PVC
2.Well Construction Permit#,
323248 16.INNER CASING OR TUBING eothernial closed-too )
TO
List all applicable irell constwc•ti(jn perinus(i.e.U1C,Cotunly,Sure,garirnnce,etc.) FROM ft. ft. ll1A\7 ETER in. TIIICKNE.SS hLATERLAL
3.Well Use(check well use): ft. n.
Water Supply Well: 17.SCREEN
FROdI .To DLAMPa•F,R SLOT SI%E TH ICKNP:SS MA'1'ERlnl.❑Agliculturnl ❑MunicipaUPublic fL ft. in.
❑Geothermal(1lcaling/Cooling Supply) L*iResidential Water Supply(single)
ft. ft. in.
❑Industrial/Conuncrcial ❑Residential Water Supply(shared)
18.GROUT
❑Irrigation ❑Walls>100,000 GPD FROM TU D' TERLM. rMPLACEhIENT MCTilOD S AMOUNT
Non-Water Supply Well: 0 r1. 20 fc. GROUT POURED
[]Monitoring ❑Recovery ft. ft.
Injection Well:
❑A uifer Recharge ft• tL
q g ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinit Barrier 19.SAND/GRAVEL PACK if a licablc
y FROM TO MATERIAL EMPLACE\IENTMETIIOD
❑Aquifer'fcst ❑Stonnwater Drainage ft. R.
❑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 1121 Remarks) FROM TO DESCRIPTION(color•hardness,soil/rock type,grain size,etc.)
0 f'• 41 f'• DIRT
4.Date Well(s)Completed: 08-25-2022 Well ID# 41 ft 41 ft ROCK
Sa.Well Location: ft. ft.
PEACHTREE RESIDENTIAL -ft. -ft.
Facility/OwncrNamc Facility lD#(ifapplicablc) ft. ft. '-
129 DABBLING DUCK, MOORESVILLE,N.C. 28117 ft. f1• JAN 0 S 2023
Physical Address,City,and Zip ft. ft.
IREDELL 4636680060 zI.REMARKS. "'
Counly Parcel identification No.(PiN)
5b.Latitude and longitude in degrees/ininutes/seconds or decimal degrees:
(iftvcll field,one IaUlong is sufficient) 22.4-tif.
35° 34.241 N 80° 53.779 NAt !!!:���8�/25/2�022
6.is(are)the well(s): ClPermanent or ❑Temporary Signature ofCcrtified Well Contractor Date
By signing this form,1 hereby certi0l that the it,01(s)was(nacre)constructed in accordance Irish
7.Is this a repair to an existing well: ❑Yes or [!]No 1511 NCAC 02C.0100 or 15d NCAC 02C.0200 It e11 Contraction Standards and that a copy
lfthis is a repair,fill out known ire/l construction fnlorination and espla/n the nature ofthe gf1his record has heen provided to the well owner.
repair under#21 reamrks section or on the back of this fo•nn.
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'Sce Over'in Remarks Box).You may also attach additional pages irnecessaly.
dri Ilcd:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 565 ft.
For multiple hells list all depthsifdi(1crent(example a-3 200'and 2 a,100') ( ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 50 a (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
lfaler level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6 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 rind Open-Lo Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) op county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over (00 000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpnn) 5 Method of test:
AIR Permit Program,1611 MSC,Raleigh,NC 27699-1611
u u i
13b.Disinfection type: TLJ Amount: !
Form G W-I North Carolina Department of Environmenhd Quality-Division of Watcr Resources I Revised 6-6-2018
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