GW1-2023-00397_Well Construction - GW1_20230103

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WELL CONSTRUCTION RECORD (GW 1) For Internal Use Only:
1.Well Contractor information:
i
RANDY OWNBEY (4.WATER ZONES
Well Contractor Name FItO3t 'to DEsCRU'TION
3214A 329 ft 330 rf•
ft. ft. 6
NC Well Conlmctor Certification Number V
AIR DRILLING I N C 15.OUTER CASING for multi-cased wells OR LiNER(if a licable)
FROM TO DIAMETER! THICKNESS MATERL1L
Company Name 0 ft- 134 ft- 6 1 "- GALV
324213 16.INNER CASING OR TUBING cothermal closed-loo
2.Well Construction Permit#: FRO31 TO DIAMETER TIIICKNFSS MATERIAL
List all applicable well construction pert nits(i.e.U1C,Canny.State, Variance,etc.) tt. ft. in.
3.Well Use(check well use): ff. ft. in.
Water Supply Well: 17.SCREEN
FROM •1.0 DIAMETER SI.0'1•SIZE Till KNESS MATF.111 1,
❑Agricultural ❑MunicipaUPublic ft.
❑Geothermal(Heating/Cooling Supply) 1'1Residential Water Supply(single)
❑industrial/Couuncreial ❑Residential Water Supply(shared) Ili.GROUT
❑h•1'i'allon ❑We[Is> 100,000 GPD FROM I TO MATERIAL EMPLACEMENT METIIODS AMOUNT
Non-Watcr Supply Well: 0 ft' 20 ft• GROUT POURED
❑Monitoring ❑Recovery ft. ft.
Injection Well:
fl. ft.
❑Aquifer Recharge ❑Groundwater Rcmcdiation
❑Aquifer Storage and Recovery ❑Salinit Barrier 19.SAND/GRAVEL PACK if a licablc
Y FRO31 TO I MATERIAL I EMPLACFMENTMETIIOD
❑Aquifer Test ❑Stormwata•Drainage ft
• ft.
❑Experimental Technology ❑Subsidence Control ft. tt.
❑Geothetmal(Closed Loop) ❑•Tracer 20.DRILLING LOC attach additional sheets if necessary)
❑Gcothemltil(I Icating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,solifrock type.•rain size,etc.)
0 f` 124 fl• DIRT
4.Date Well(s)Completed: 6-6-2022 Well ID# 124 ft- 345 ft• ROCK
5a.Well Location:
B RIAN BAKER ft. rt. h- .::., V'
Facility/OwnerNamc ft. ft. 1 N (5 J ' 023 Facility JHtV V Lll .1
465 OSTWALT AMITY RD,TROUTMAN,N.C. 28166 rf. a•
Physical Address,City,and Zip ft. ft.
IREDELL 4751229956 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/Ininutes/seconds or decimal degrees:
(if well field,one lot/long is sufficient)
22.Ccl•tiTi n:
350 41.423 N 800 50.314 W 6/6/2022
6.Is(are)the well(s): 011ermanent or ❑Temporary Signature orCerti led Wcll Comr,lctor Date
By signing this jbrnn,1 hereby certih,that the Ive/l(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or L7No /Sit A'CAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a cagy
f this is a repair.fill o l known well construction information and explain the nature of the of this record has keen provided to the well owner.
repair under 1121 remarks section or an 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'See Ovcr'in Remarks Box).You may also attach additional pages if nccessaly.
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Tota►well depth below land surface: 345 (ft.)
For multiple wells list all depols ifdiQerent(evannple-3 a 200'and 2 a 100') Submit this GW-I within 30 days of well completion per tit following:
10.Static water level below top of casing: 134 ft 24a. For All Wells: Original form to Division of Water Resources (DWR),
f n-ater level is above cashg,use'••I''• (ft.) Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (ill•) 24b.For Injection Wells:Copy to DWR, Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12,aVeer,construction method: 24a For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) 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
13a:Yield(gpnt) O Method of test:
AIR Permit Program,161 I MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount:
Form GW-I North Carolina Depamuenl of Environmental Quality-Division of Water Resources Revised 6-6-2015