GW1-2023-00400_Well Construction - GW1_20230103

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
I.Well Contractor Information:
NEILL PARDUE
14.WATER ZONES
Well Contractor Name FROJI .1.0 DF,SC111111TION
2609A 309 ft- 310 i
Ct. ft. I I
NC Well Contractor Certification Number
AIR DRILLING I N C 15.OUTER CASING for multi-cased•svclls OR LONER if a licablc)
FROM TO DL\METER. TIIICKNESS MATERIAL
p 65 ft. 6 in.
Company Name � PVC
329244 16.INNER CASING OR TUBING eothernsal closed-loon)
2.Well Construction Permit th FROM TO DIAMETER THICKNESS MATERIAL
List all applicable ivel/construction pennils(i.e.UIC,Cotnuy,State,V(iriance,cle.) ft. ft. in.
3.Well Use(check well use): rl. ft. in.
Water Supply Well: 17.SCREEN
FROM 'I'O DIAMETER SI,O'I'SIZF, 'I'll ICKNtSS MATERIAL
❑Agricultural ❑MunicipaUPublic ft. ft. in.
❑Geothennal(1-leating/Cooling Supply) IJResidential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) ls.GROUT
❑h•ri ation ❑Wells> 100,000,GPD FROMI TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 20 ft- GROUT POURED
[]Monitoring ❑Recovery ft. ft.
Injection Well:
ft.❑Aquifer Recharge ❑Groundwater Remediation ft.
19.SAND/GRAVEL PACK0faVDliCabI0
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METIIOD
❑Aquifer Test ❑StornnvaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessar
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM I TO DESCRIPTION(color,hardness,solltrock type, rnin size,etc.)
0 f' 55 f'• DIRT
4.Date Well(s)Completed: 6-7-2022 Well ID# 55 1325 f' ROCK
5a.Well Location: rl. tt.
LAWRENCE OWNBEY ft. «,
Facility/Owner Name ft.
facility IDI!(ifapplicublc) +.
301 SHEPHARD RD MOORESVILLE,N.C. 28115 JAiNJ
Physical Address,City,and Zip Ct. ft.
IREDELL 4659755139 21.REMARKS
County Parcel identification No.(PIN)
5b.Latitude and longitude in degreeshninutes/seconds or decimal degrees:
(ifwcll field,one IaUlong is suft cicnQ 22.C ion:
350 38.476 N 80- 49.335 W 6/7/2022
6.Is(arc)the wcll(s): LlPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby cerl Ji•that the we/l(s)was(were)constructed in accordance with
7.IS this a repair to tin existing well: ❑Yes or CJNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
lfthis•is a repair.Jill out known well construction information and explain the nature of the q/7his record has been provided In the well 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 325 (ft.)
Fa•medtiple w if ells list all depths dd(frrent(erannple-3 a 200'and 2 a 100') ( Submit this GW-I within 30 days of well completion per the following:
10.Static water level below top of casing: 40 24a. For All Wells: Original Corot to Division of Water Resources (DWR),
If (ft.)water level is above rasing,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 depaitmcnt of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program, 161 1 MSC,Raleigh,N C 27699-161 I
13a.Yield(gpnt) 0 Method of test: AIR P I
13b.Disinfection type: HTH Amount: I `
i
Form G W-I North Carolina Department of Environmental Quality-Division of Watcr Resources Revised 6-6-20I8
I'