GW1-2023-00402_Well Construction - GW1_20230103

!
Ji
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well.Contractor Information: I '
NEILL PARDUE
-14.WATER ZONES I j
Well Contractor Name FROM .1.0 DESCRIPTION
2609A 489 ft- 490
I
ft-
NC Well Contractor Certification Number ft. ft.
AIR DRILLING I N C I5.OUTER CASING for multi-cased i'velis OR LiNER if a licable)
FRO\I TO DI,\METER ? TIIICKNESS MATERIAL
ft. 87 ft. 6 iih.
Company Name 0 PVC
317599 16.INNER CASING OR TUBING(geothermal closed-loonl
2.Well Construction Permit/h FROM I TO I DIAMETER I TIIICKNESS IMATERIAL
List all applicable+cell con.stuction permits(i.e.U/C,Counly,State,Variance.etc.) fL ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM •1.0 DIAMFAT.14 SLOTSIZE I THICKNESS I MATF,RIAI.
❑Agricultural ❑MunicipaVPublic ft. ft. in.
❑Geothermal(Hcating/Cooling Supply) L7Rcsidential Water Supply(single) ft. ft, in.
❑Industrial/Commercial ❑Residential Water Supply(shared) -IS GROUT
Olt-ri gation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METIIOD S AMOUNT
Non-Water Supply Well: 0 1" 20 ft• GROUT POURED
❑Monitoring ❑Recovery ft. R.
Injection Well:
ft, ft.
❑Aquifer Recharge ❑Groundwater Remediation
19rSAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO MATERIAL I EMPLACEMCNTMETIIOD
❑Aquifer Test ❑SlornwaterDrainage ft. ' ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Gcothennal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional'sheets if necessar•)
❑Gcothennal(Hcating/Cooling Return) ❑Other(explain under 1121 Remarks) FRO?I I TO DESCRIPTION(color,hardness,soWrock type:grain size,etc.)
0 177 f DIRT
4.Date Well(s)Completed: 5-1 9-2022 Well ID# / 77 R' 505 f' ROCK
5a.Well Location: fL ft.
LAKEMIST HOMES B. ft.
^ _
Facility/Owner Name Facility ID11(ifapplicablc) ft. ft. � -6-11,_'�,_„ va!
116 RYLEIGH DAN LOT#27 MOORESVILLE,N.C. 28117 ft. ft. JAN
Physical Address,City,and Zip ft. ft.
IREDELL 4654781493 21.REMARKS n;i,;
(7i ,.r.G
County Parcel identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one tat/long is sufficient) 22.Certiflegoo `
35° 31.030 N 80° 49.284 W egl 5/19/2022
6.Is(are)the well(s): OPermanent or ❑Temporary Si tare of Certified Wel Contractor Date
lay signing this form l hereby cert Jv Not the well(v)was(were)constructed in accordance with
7.is this a repair to an existing well: ❑Yes or PJNo ME NCAC 02C.0100 or 15A NCeIC 02C.0200 Well Construction Standards ran/Not a copy
//'this is a repair,,lill out known well construction iq/orniation and explain the nature of fhe of the record has been provided to the well.owner.
repair antler 021 renmrks section or on the back of this faun,
23.Site diagram or additional well details:
8.For Geoprobe/DPT o•Closed-Loop Geothermal Wells having the same 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'Sec Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBI411TTAL INSTRUCTIONS,,
9.Total well depth below land surface: 505 (ft.)
Ea•nahiple wells list all depths?/'different(esantple.-9@200•and 2 n 100') Submit this GW-I within 30 days ol'Well completion per the following:
40 Z4a, For All Wells: Original form'to Division of Water Resources DWR
10.Static water level below top of casing: i ( ),
1f hrater Jewel is above casing,use^+•• Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6 24b.For Injection Wells:Copy to DIWR, Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699;1636
12.Well construction method: I '
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: 24d. MSC,Raleigh,NC,For Water We is producing over 100,000 GPD: Copy to DWR,CCPCUA
12 t Program,IC,I 1 27699-1611
13a.Yield(gpiu) Method of test:AI R Penn
13b.Disinfection type: HTH Amount:
i
Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources i Revised 6-6-2018