GW1-2023-00386_Well Construction - GW1_20230103

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WELL CONSTRUCTION RECORD (GW 1) For Internal Use Only:
L Well Contractor Information:
RANDY OWNBEY
la.WATER ZONES l i
Well Contractor Name FROM I'O DESCRIPTION
3214A 529 f'• 530 ft.
NC Well Contractor Certification Number
fI
AIR DRILLING I N C 15.OUTER CASING multi-cased;wells)OR LINE if a licable
FRU\I 'I'U DIAMETER I TIIICKNESS MATERIAL
in.
p f 135 ft•
Company Name t. 6 ' PVC
329644 16.INNER CASING OR TUBING eothcrmat closed-loop)
2.Well Construction Permit#: FROM I TO DIAMETER THICKNESS MATERIAL
List all applicable well contraction pennies(i.e.U1C.County,Stale. Viiriaace.cle.) ft. ft. in.
3.Well Use(check well use): f, ft. in.
i
Water Supply Well: 17.SCREEN
FROM 'PO DIAMETER SLOTSIZF THICKNESS I MA-I•ERIAI.
❑Agricultural ❑MunicipaUPublic ft.
❑Gcothcnnal(Pleating/Cooling Supply) CResidential Water Supply(single)
ft. ft.
❑industrial/Commercial ❑Residential Water Supply(shared)
18:GROUT-
❑irrigation ❑Wei Is> 100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: p rt. 20 rt. GROUT POURED
❑Monitoring ❑Recovery ft, ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation ft. ft.
'
❑A uifcr Storage and Recover 19.SAND/GRAVEL PACK if-applicable)
q g y ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Storinwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft, ft.
❑Geothermal(Closed Loop) ❑Tracer 20.rDRiLLING LOG attach additinnal sheets if necessary)
❑Gcothcnnal(1-1cating/Cooling Rctum) ❑Other(explain under 921 Remarks) FRU>I TU DESCRIPTION(rotor,hardness,solUrack type,'rain site,cic.)
0 ft. 125 ft DIRT
a.Date Well(s)completed: 07-07-2022 Well IDt/ 125 ft 545 ft• ROCK
5a.Well Location: ft. ft.
TONY CASCADDON
Facility/Owner Name Facility ID0(ifapplicable)
2124 BUFFALO SHOALS RD,STATESVILLE,N.C. 28677
Physical Address,City,and Zip ft. ft. �,.;-•7 ;c,� t�f t
IREDELL 4712602341 21•REMARKS
County Parcel identification No.(PiN)
5b.Latitude and longitude in degrees/ininutes/seconds or decimal degrees:
(ifwell field,one]at/long is sufficient) 22.Certi Ion:
35e 42.471 N 800 57.593 W
7/7/2022
6.Is(are)the well(s): InPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this Joan•I hereby cm•tifv t/rat the we//(s)was(were)carsirticied in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 01C.0I00 or 15A NCAC 01C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature•of the of(his record has been provided to the we!l owner.
repair under#21 remarks section or 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 1 GW-I is needed. ,Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You tixay also attach additional pages if necessary.
drilled:
24.SUBMITTAL INSTRUCTIONS9.Total well depth below land surface: 545 ft.
Fornrultiple wells list all depths i/diQerent(erample-3 a.100'and 1 a 1001 ( ) Submit this GW-I 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),
/J'aater level is above rasigq,five^+^ ( ) 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: 24c.For Witter Supply'and Open-too Geothermal Return Wells Co
(i.e.auger,rotary,cable,direct push,etc.) county environmental hculth department of the county where installed Copy to rile
FOR WATER SUPPLY WELLS ONLY: tad.For Water Wells producing over 100 000 GPD• Copy to DWR,CCPCUA
13a.Yield m 3 AIR Permit Program, 16l I MSC,Raleigh,NC 27699-161 I
(gP ) Method of test:
13b.Disinfection type: HTH Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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