GW1-2023-00391_Well Construction - GW1_20230103

WELL CONSTRUCTION RECORD (GW 1) For Internal Use Only:
i '
I.Well Contractor Information: i
RANDY OWNBEY
-14.WATER ZONES
WcI1ConlractorNamc 2-OUTER
TO DESCRIPTION
3214A 90 ft. p
NC Well Contractor Certificalion Number ft.AIR DRILLING INC ASING for multi-cased wells)OR LINER if a;Iimble)O DI,\,METF.R� THICKNESSRh\L
Company Name 9 it• 6 Jill.
323246 16.INNER CASING OR TUBING eotliermal closed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIALList all applicable trell cvmsn uc9ioa perm m
its(i.e.U1C,Co, ty,Stale,1(a,kn cc,etc.) ft. ft. in.
3.Well Use(chccl(well use): ft. ft.
Water Supply Well: 17.SCREEN
❑Agricultural FROM To )tAMEIE.R st.oTSIr,E rlucKNesS MATERIAL b ❑MunicipaUPublic tt. ft. in.
❑Geothermal(l•leating/Cooling Supply) L*jResidential Water Supply(single)
ft. ft. in.
❑IndusU-ial/Commercial ❑Residential Water Supply(shared)
IS.GROUT
❑IrriI atiolt ❑Wells> IOO,000 GPD FROM TO MATERIAL EMPLACEMENT Mr•,TIIODSAMOUNT
Non-Water Supply Well: 0 tt. 20 rL GROUT POURED
❑Monitora•ing ing ❑Recovery n.
Injection Well: n
❑A uifer Recharge ft. A.❑GrodaerRemeiaton❑Aquifer Storage and Recovery ❑Salinity Barrier 19.;ND/GRTV EL PACK if a licable
FROMATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. rt.
❑Experimental Technology ❑Subsidence Control
❑Gcotltennal(Closed Loop) ❑Tracer 20.DRILLING LOC attach additional sheets if necessary)
❑Gcotherntal(pleating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillrock ty e,grain siu,etc.
p rt. 29 n• DIRT
4.Dale Well(s)completed: 6-14-2022 Well ID# 29 a• 505 ft- ROCK
5a.Well Location: ft. ft.
PEACHTREE RESIDENTIAL ft. rL
Facility/Owner Name Facility ID#(irapplicable) ft. ft. ''�( r+1 y i-10"
125 DABBLING DUCK CIRCLE,MOORESVILLE,N.C.28117 rt. rt. , q
Physical Address,City,and Zip -
IREDELL 4636579887
21.REMARKS i. {" ,';1::::;:^'") i'f::ZC•�:::3l�fi,�
County Parcel Idcnti[icution No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one la/long is sufficient) 22.Certilic
350 34.132 ,IN 800 53.469 N,
6/14/2022
6.Is(ire)the%vell(s): InPermanent or ❑Temporary Signature ofCertiGed Well Contractor Date
Bysigning this form,l hereby certify that thcnrell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or I!INo /5A NCACO2C.0100 or 15A NCAC 02C.0200 IVell Co,,.st•tction Sr(aulorrls am!that a copy
f this Is a repair,fill out known well construction in/brntation and explain the nature of the of thiv record laic beet provided io the well owner.
repair under QI reuarkv section or on the back ofthis 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'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 muhiple bells list all depths i/di/ferenr(example-3 t,200'and 20a 100') Submit this GW-I within 30 days of well completion per the following:
10.Static water level below lop of casing: 60 (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
f hater level IS above casfikg,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:
(i.e.auger,rotary,cable,direct push,etc.) 24c.For Water Supply and Open-Loo)Geothermal Return Wells•Copy to the
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: I
24d.For Water Wells producing over 100 000 GPU Copy to DWR,CCPCUA
13a.Yield(gpm) 20 Method of test:AIR Permit Program,161 1 MSC,Raleigh,NC 27699-I6l 1
13b.Disinfection type: HTH Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources i
� I Revised G-6-..o
018
" i i