GW1-2023-00383_Well Construction - GW1_20230103

WELL CONSTRUCTION RECORD (GW 1) For Internal Use Only; j
a •
1,'Well Contractor Information:
RANDY OWNBEY 14.1VATERZONES u
Well Contractor Name FROM ro DESCRI11,11ON
3214A 2s9 ft- soo ft l
ft.
NC Well Contactor Certification Number
AIR DRILLING I N C I5.OUTER CASING for multi-cased wells OR LINER if•a livable
FROM TO WAMETERI THICKNESS _ MATERIAL
Company Name 0 ft. 78 ft. 6 ! tin. PVC
16.INNER CASING OR TUBING. eothermal closed-loop
2.Well Construction Permit#: FROdI TO DIAMETER I I THICKNESS MATERIAL
List a1l applicable mall cmtstnrevion permtr(I.e.U1C,County,State,Variance,etc.) ft. ft. + in.
3.Well Use(check well use): ft. ft. I in.
Water Supply Well: 17.SCREEN
FROM 'I.O 1)IAM K'rER S1.0'11SIZE THICKNESS MATERInI.❑Agricultural ❑Municipal/Public (t. ft. in.'
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
ft. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared)
18.GROUT
InIrri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 rt• 20 ft GROUT POURED
[]Monitoring ❑Recovery ft. ft,
Injection Well:
❑A uifer Recharge ❑Groundwater Remcdiation ft• rt.
19.SAND/GRAVEL PACK if applicable)❑Aquifer Storage and Recovery ❑Salinity Barrier -ROM TO MATERIAL EMPLACE<11GNTMETIIOD
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control
❑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,soil/rock fN
Tc.grain size,etc.)
p rt. 68 r'• DIRT
4.Date Well(s)Completed: 07-19-2022 Well ID# 68 ft 68 ft ROCK
Sa.Well Location: ft. ft.
TRAVIS FOSTER 11. ft. ,,T ti
Facility/Owner Name Facility lD#(ifapplicable) ft. ft. r
1575 SHINNVILLE RD,CLEVELAND,N.C. ft. -
Physical Address,City,and Zip ft, ft
IREDELL 21.REMARKS ---
County Parcel ldentification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Iat/long is sufficient) 22.Certif n:
350 41.335 N 80- 47.135 w 7/19/2022
6.Is(are)the well(s): ❑Permanent or ❑Temporary Signature orCerti ied Well Contractor Date
By signing this form,/hereby cart fv that the"Iel/(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or InNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
/"this is a repair•fill out known ivell construction information and explain the nature o/•the of this record has been provided to the ivell owner.
repair under#21 rentarkr section or on the back of this feral.
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-I is needed. Indicate TOTAL NUMBER of wells (add'Sce Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 505 (ft)
For multiple wells list all depths h/di.(ferent(example-3 a,200'and 2 a@i 100) 1 Submit this GW-1 within 30 days of well completion per the following:
10.Static waterlevel below top of casing: 50 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
!f water level is above rasing,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 27699-1636
12.Well construction method:(i.e.auger,rotary,cable,direct push,etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wclis producing aver 100 000 GPD• Copy to DWR,CCPCUA
13a.Yield(gpm) 20 Method of test:AIR Permit Program, I61 I MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount:
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Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018