GW1-2023-00399_Well Construction - GW1_20230103

WELL CONSTRUCTION RECORD (GW 1) For Internal Use Only:
1.Well Contractor Information:
RANDY OWNBEY
14.WATER ZONES.- -
WellContractorName FRO31 'r0 DESCRII''!'ION
3214A 269 ft• 270
ft-
ft. ft. l
NC Well Contractor Certification Number I
AIR DRILLING I N C 15.OUTER CASING(for multi-cased iyells)OR LINER(if a licable)
FROM TO DIAMETER ' IIHCKNESS MATERIAL
Company Namep ft. 60 ft. 6 I ;n. PVC
329093 16.INNER CASING OR TUBING e6thermal closed-too
2.Well ConSfYDCflOn Permit#: FRO\i TO DIAMETER TnICKNESS MATERIAL
all applicable well construcvimh pertnits(i.e.U1C,Comity,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft.
Water Supply Well: 17.SCREEN
FROM 11.0 DIAMETER SLOTs17,E THICKNESS MATERIAL.❑Agricultural ❑Municipal/Public ft. ft. in,
❑Geothermal(Heating/Cooling Supply) IJResidential Water Supply(single)
ft. ft. in:
❑Industrial/Commercial ❑Residential Water Supply(shared)
18:.GROUT
❑lyd ration ❑Wells>inn nn0 GPD FRO\I TO MATERIAL EMPLACEMENTMETIIOD&AMOUNT
Non-Water Supply Well: 0 fL 20 ft, GROUT POURED
❑Monitoring ❑Recovery ft. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Retnediation ft. ft.
❑Aquifer Storage and Recovery ❑Salinit Barrier 19.SAND/GRAVEL PACK if applicable)
y FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StonnwaterDrainage ft. ft.
❑1 xperimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer .20.DRILLING LOG'attach'additionaUshcets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soillrock type.grain size,cIc
0 rt. 50 f'• DIRT ,
4.Date Well(s)Completed: 10-26-2022 Well IDli 50 ft• 285 ft ROCK
Sa.Well Location: ft. ft.
RANCE XIONG rt. rt. �4 f a:
�a i--.
Facility/Owner Name ft. ft.Facility iD/1(ifxpplicablc) i
150 TALONS TRAIL,STATESVILLE,N.C. 28625 ft. - rt. JAN
Physical Address,City,and Zip ft. ft. t
;-a
IREDELL 4752106816 21.REMARKS nv ' , s,;,;-zOG
County Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Iat/long is sufficient) 22.Certifiea
35° 42.169 N 800 51 .193 W.
• , 10/26/2022
6.Is(are)the well(s): IJPermanent or ❑Temporary Signature or Certified Well Contractor Date
i
By signing thisform,1 hereby cerlijj,that theavell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or C1No 1511 NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
lfthis is a repair•,#ll out known well construction information and egtlain the nature of the of this record has peen provided to the well owner.
repair under#21 renmrkv section or on the back of this forin.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the sane You-may use the back of this page to provide additional well construction info
construction,only 1 GW-1 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.•Total well depth below land surface: 285
ft.
For nathiple wells list all depths i/'di(jerent(cramp/e-3 a.200'and 2@100') ( ) Submit this GW-1 within 30 days of well completion per(he following:
10.Static water level below top of casing: 50 It I 24a. For All Wells: Original form to Division of Water Resources (DWR),
jivater level is above casing,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: 24c.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:
p 24d.For Water Wells producing over 100 000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) 5 Method of test:
AIR Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount:
Form G W-1 North Carolina Department or Environmental Quality-Division or Water Resources Revised 6-6-2018
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