GW1-2023-00408_Well Construction - GW1_20230103

WELL CONSTRUCTION RECORD (GW 1) For Internal Use Only: j
I.Wc11 Contractor Information:
RANDY OWNBEY `
14.WATER ZONES ( i
Well Contractor Name FROM To DESCRIPTION
3214A 3s9 ft• 390 I
ft. ft.
NC Well Contractor Certification Number V
AIR DRILLING I N C 15.OUTER CASING for multi-cased wells OR LiNER(if a Itcable)
FRU\I TO DIAMETER TIIICKNESS MATERIAL
Company Name 0 ft' 113 ft. 6 , in GALV
317591 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#. FRO\I TO DIAMETER I THICKNESS MATERIAL
List all applicable bell construction permits(i.e.UIC County,State, ilariauce,etc.) ft• ft. in.
3.Well Use(check well use): ft. ft.
Water Supply Well: 17.SCREEN
❑Agricultural ❑MunicipaUPublic FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
ft. ft.
❑Geothermal(tieating/Cooling Supply) [!]Residential Water Supply(single)
ft. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared)
18.GROUT
❑irri gation ❑Wells>100,000 GPD FRO\I TO MATERIAL EMPLACEMENT METIIOD&AMOUNT
Non-Water Supply Well: 0 "' 20 fL GROUT POURED
❑Monitoring ❑Recovery ft. ft.
Injection Well:
❑A uifer Recharge ❑Groundwater Remediation ft. ft.'
❑Aquifer Storage and Recovery ❑Salinit Barrier 19.SAND/GRAVEL PACK if a Iicable
y FROM TO MATERIAL EMPLACEMENTMETIIOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ft. ft.
❑GCotltermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional,sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soil/rock type.praln size.etc.
,1 0 ft• 103 ft- DIRT
4.Date Well(s)Completed: `t-7-2022 Well ID# 103 ft• 405 fL ROCK
5a.Well Location: ft. ft.
1
LAKEMIST HOMES ft. ft. F ,_a,,._,
Facility/Owner Name Facility iD#(if applicable) ft. ft.
128 RYLEIGH DAN RD,MOORESVILLE,N.C. 28117 rt. rr. J A N 0 2023
Physical Address,City,and Zip ft. ft.
IREDELL 4654780649 21.REMARKs lntc;ta � -y Y;:
�)' 'a ltl SL)t7
Counq' Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certi ation:
350 31.712 N 80° 49.317 W 4/8/2022
6.Is(are)the well(s): [!]Permanent or ❑Temporary Signature of Certified WCII Contmctor Date
By signing this,fornt,i hereby certify that rhe,well(s)was(here)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or IdNo 15A NCAC 02C.0100 or I5A NCAC 02C.0200 lVel/Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 reworks section or on die 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 1 OW-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: 405 ft.)Formultipte%veils list alideprinsifdd cr crent(example-3200'aud1@100') ( Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 50 ft 24a. For All Wells: Original form to Division of Water Resources (DWR),
lfxwtet level is shove 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-Lo Ip 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(gpm)25 Method of test:
AIR Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount:
Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources i Revised 6-6-2018