GW1-2023-00409_Well Construction - GW1_20230103

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WELL CONSTRUCTION RECORD (GW-1) For Internal Usc Only:
1.Well•Contractor Information:
RANDY OWN BEY i
'14.'WATER ZONES
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WellContractorName FROM 1.0 DESCRIPTION
3214A 569 ft 570 rt.
ft. ft.
NC Well Contractor Certification Number
15.OUTER,CASING. for multi-cased'weIts OR LiNER,ira livable
AIR DRILLING I N C FROM TO Dl,\METER 1 THICKNESS MATERIAL
Company Name 0 ft. 80 ft. 6 1 Io. I PVC
314425 16.INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit#: FROM I TO I DIAMETER I TIHCKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Comity.State,Variance,etc.) ft. it.
3,Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER I SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. tt. in.
❑Geothermal(Heating/Cooling Supply) [!]Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT,
❑Irri ation - ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non=Water Supply Well: 0 rt. 20. f`• GROUT POURED
❑Monitoring ❑Recovery tt. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
'19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO MATERIAL I EMPLACEMENT METI(OD
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. I ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional"sheets if necessary)- -
FROM TO DESCRIPTION color,hardness,soillrock type. rain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 tt, 70 f`• DIRT
4.Date Well(s)Completed: 4-20-2022 well ID# 70 ft• 585 f`• ROCK
Sa.Well Location:
ft. ft.
PEACHTREE RESIDENTIALFacility/Owner Name Facility lDN(if applicable) ft. ft.
118 COPPER PINE LANE,DAVIDSON,N.C. 28036 ft. ft. Al
Physical Address,City,and Zip ft. ft.
IREDELL 4664860744 21.11EMARKS
Comity Parcel Identification No.(PiN)
5b.latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.CertifiC
350 30.501 N 80° 47.136 W 4/20/2022
6.Is(arc)the well(s): InPermanent or ❑Temporary Signatti a of Certif6d Well Contractor Date
By signing this forni,I hereby certify that ilia ivell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well 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 remarks section or on ilia back of this fo ni.
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'Sce Over'in Remarks Box).You may,also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 585 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For nndtiple wells list all depths ifdi•Qerent(eramp/e-3@200'and 2@1001
10.Static water level below top of casing: 50. (ft) 24a. For All Wells: Original form,to Division of Water Resources (DWR),
If water 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(lUC)
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.For Water Wells producing over;100,000 GPD:Copy to DWR,CCPCUA
Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpnl) 5 Method of test:AI.R i
13b.Disinfection type: HTH Amount:
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Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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