GW1-2023-00380_Well Construction - GW1_20230103

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WELL CONSTRUCTION RECORD (GW 1) roe Internal Use Only: I
I.Well Contractor Information:
RANDY OWNBEY
14,WATER ZONES a
Well Contractor Name FROM r0 DESCRIPTION
3214A 429 ft- 430 ft-
NC Well Contractor Certification Number I
AIR DRILLING I N C 15.OUTER CASING for multi-casedlwells OR LINER(if a I*cable)
FRU\1 TO DL\METER I TIIICKNESS M.\TERL\L
Company Name 0 f`, 136 ft 6 I I" I JPVC
330418 16.INNER CASING OR TUBING(geothermal closed-lob
2.Well Construction hermit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well constrUctiat permits(i.e.UIC,County,State,Variance,etc.) ft. ft. i in.
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3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FRO\I '1'O DIAMETER '. SI.OTSIZE THICKNESS MnTER1A1.
❑Agricultural ❑Municipal/Public ft. ft. in. i
❑Geothermal(Fleating/Cooling Supply) CiResidential Water Supply(single) ft. ft. in.
[ Industrial/Commercial ❑Residential Water Supply(shared) 18,GROUT
❑irri ation ❑Wei Is> 100,000 GPD FRO\1 TO MATF.RL\L EMPLAMIENTMETIIOD&AMOUNT
Non-Water Supply Well: - 0 D. 20 ft• GROUT POURED
❑Monitoring ❑Recovery ft. -ft.
Injection Well:
rc. ft.
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinit Barrier 19.SAND/GRAVEL PACK if n licablc
Y FRO\t TO MATERIAL EMPLACEMENTMETIIOD
❑Aquifer Test ❑Stormwatcr Drainage ft• ft.
[]Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Traccr 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Ncating/Cooling Return) ❑Othcr(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soll/rock type.grain sire,etc.)
0 f`• 126 f`• DIRT
4.Date wc11(s)Completed: 08-04-2022 Well ID/1 126 fc• 445 f` ROCK
5a.Well Location:
GROVER MEETZE rt. ft.
Facility/Owner Name Facility 1D11(if applicable) ft. ft.
1661 MECKLENBURG HWY,MOORESVILLE,N.C. 28115 ft.
r ^�
Physical Address,City,and Zip ft. ft. ,�+.T. 4 ..v •Y' �zV �_.�
IREDELL 4655048377 21.REMARKS
Count I ��
Y Parcel Identification No.(PIN)
2023
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �'•7'j-:7 UI A
(if well field,one hit/long is sufficient) 22.Certifiea' ^ rA oL)1 iQ
35° 32.027 N 80° 50.765 W 8/4/2022
6.ls(are)the well(s): nPermanent or ❑Temporary Signatu e orCertifiIiilfWclI Montractor Date
Bysigning thisforne 1 hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or I'No ISA NCAC 02C.0100 or 15A A'CAC 02C.0200!Yell Construction Standards and that a copy
10his is a repair,fill out known well construction information and explain the nature of the gfthis record has peen provided to the well owner.
repair under#21 remarks section at-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 I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'Scc Ovcr'in Remarks Box).You may also attach additional pages if necessary.
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 445 ft
For multiple wells list all depths ifdii event(erample-3 a 200'and 2 an 100') ( ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below lop of casing: 50 ft 24a. For All Wells: Original font to Division of Water Resources (DWR),
lfwater level is above casing,use"+" ( ) Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
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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 and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health dcpart ncnt of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
10 Permit Program,161 1 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:AIR 1
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13b.Disinfection type: H I H Amount
Form G W-I North Carolina Department of Environmental Quality Division of Water Resources P• Q Y- I Revised 6-G-20I8
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