GW1-2023-00395_Well Construction - GW1_20230103

WELL CONSTRUCTION RECORD (GW 1) For internal Use Only:
I.Well Contractor Information:
RANDY OWNBEY
14.WATER ZONES y
Well Contractor Name MTMNERCASING
1'O DESCRIPTION3214A 90rtNC Well Conlraclor Ccrtificalion NumberAIR DRILLING INC SING for multi-cased�velis OR LINER(if a licable)O DI, ETTIIICKNESSpCompanyZ111c ft 6 in•317598 SING OR TUBING( eothermal closed-too2.Well Construction Permit#: O DL\METERTList all applicable well conu•htction permits(i.e.UIC.Cohmty.State•Varian,,,, ft. in.
3.Well Use(check well use):
Water Supply Well: 17.SCREEN
❑Agricultural FROM TO DIAMETER SLOT SIZE •r1OC-ISS MATERIAL
b ❑Municipal/Public tt. ft. in.
❑Geothermal(licating/Cooling Supply) C1Residential Water Supply(single)
ft. ft. in.
❑Indust rial/Commercial ❑Residential Water Supply(shared)
i8.GROUT
❑ anion ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT h1ETllOD 3 AMOUNT
Non-Water Supply Well: 0 ft 20 ft• GROUT POURED
❑Monitoring ❑Recovery rt. rt
Injection Well:
❑A uifer Rechargeft• fi.
q g ❑GroundwatFRemediation❑Aquifer Storage and Recovery ❑Salinity Bar 19.;ND/GRAVEL PACK if applicable)
❑Aquifer Test ❑Stormwater Drainage ft. TO ft. MATERIAL EMPLACEMENTMETHOD
El Experimental Technology ❑Subsidence Control
❑Gcothernial(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothemral(Hcating/Cooling Return) ❑Other(explain under#21 Remarks) I
FROM TO DESCRIPTION(color,hardness,soil/rock lyim grain size.etc.)
p rl. 92 n. DIRT
4.Date Well(s)Completed: 05-26-2022 Well ID# 92 ft 505 ft• ROCK
5a.Well Location: ft. ft.
LAKEMIST HOMES ft. ft.
Fu ility/Owner Name Paeility iD0(if applicable) RRENIAR
ft. l a121 RYLEIGH DAN PLACE LOT#4,MOORESVILLE,N.C.28117Physical Address,City,and Lip ft.IREDELL 4654686398 Ks.
County Parcel identification No.(PiN) I
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.Certifieati
350 31.518 N 80D 49.311 W .i !te:�: 5/26/2022
6.IS(arc)the well(s): [']Permanent or ❑Temporary Signature ofCertificdOWcll Contractor Dale
Dy signing this form,l hereby certJi,that the we//(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or [9No iSA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Can imctian Standards and that a copy
?/'this is a repair.,/ill out known well construction dn/bri ation and eeplain the nantre of the of this record has heen provided to the we//owner.
repair under Ih21 remarks section or on the back ofthic form.
23.Site diagram or additional well details:
8.For Gcoprobe/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-I is needed. Indicate TOTAL NUMBER of wells (add'Scc Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
24.SUBMITTAL INSTRUCTIONS
9.'I'otal well depth belowland surface: 505
Foruudtiple wells list all depths i/dfferent(erample-3 tt,200'and 2 cOi 100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 60 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
df water level is above rasdng,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 We Is:
Copy to the
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over'100,000 GPD• Copy to DWR,CCPCUA
(t;l
13a.Yield 1m) O Method of test:AIR Pcrnit Program, 1611 MSC,Raleigh,NC 27699-1611
,
I3b.Disinfection type: HTH Amount:
I
Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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