GW1-2023-00410_Well Construction - GW1_20230103

WELL CONSTRUCTION RECORD (GW 1) For Internal Use Only: �
I.Well Contractor Information:
RANDY OWNBEY
P I
MWATERZONESWell Contractor Name DESCRIPTION
3214A
NC Well Contmclor Certification Number
A I R D R I L L I N G I N C 15.OUTER CASING for multi.cased wells Oi(if a Ileable)
FRO3i TO DIAMETER' SS MATERIAL
Company Name 0 ft. 32 ft• 6 in. PVC
319151 16.,INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit#: FROM TO DIAMETER ITIIICKNESS A1ATERIAI.
List all applicable well construction perinits(i.e.UIC,County,State,l4ariance.etc.) ft. ft. In.
3.Well Use(check well use): tt. tt. in.
Water Supply Well: 17.SCREEN,'
❑A*ricultuml FROM TO DIAMETER. SLOT SIZE 'THICKNESS MATERIAL b ❑Municipal/Public ft. ft. in.
[]Geothermal(Heating/Cooling Supply) inResidential Water Supply(single)
ft. ft. In.
❑industrial/Commercial ❑Residential Water Supply(shared)
18:GROUT
❑lrrl anion []Wei Is>100,000 GPD FROM TO MATERIAL EMPLACEafENTMETiIOD B•AMOUNT
Non-Water Supply Well: 0 rt. 20 ft. GROUT POURED
❑Monitoring ❑Recovery ft. ft.
Injection Well:
❑A uiferRechar a Groundwater Renediation
❑Aquifer Storage and Recovery 19.SAND/GRAVEL PACK if n licable
❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stonmwater Drainage ft• ft.
❑Experimental Technology []Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(lieating/Cooling Return) ❑Other(explain under#21 Remarks) TO DESCRIPTION(color,hardness,soiVrock type, rain size,etc.)
0 n. 22 rL DIRT
4.Date Well(s)Completed: 4-11-2022 Well ID# 22 fL 205 ft. ROCK
Sa.Well Location: ft. ft.
BWA BUILDERS fI.
Facility/Owner Name + v r z
Facility iD#(if applicable) ft. ft. .• -= •52 ;t.,,,,'1•.�.r`
130 ALBANY DR,MOORESVILLE,N.C. 28117 -ft. ft. JAN
Physical Address,City,and Zip ft. ft.
IREDELL 4669-11-8656 21.REMARKS011
�G
N
County Parcel identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one Iat long is sufficient) 22.Certit;c
350 38.132 N 80- 48.424 W
4/11/2022
6.fs(are)the well(s): IJPermanent or ❑Temporary Signature ofCertifred Well Contractor Date
By signing thisJbrm.1 hereby certify that the ivell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or InNo 15A NCAC 02C.0100 or 15A NCAC 02C.i1200 Nell Con.simclion Standards and that a copy
I/7his is a repair•fill out known well construction in%rnnation and explain the nature of the of this record has been provider/to the well owner.
repair under U21 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: 205 (ft.)
For nudriple wells list a1!depths ifd ffcrent(eranipllee-3 tt 200'and 2@a 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),
jpvater level is above casing,use"+ Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection 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-LooG p' cothermal 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) 20 Method of test:AIR Permit Program,161 I MSC,Raleigh,NC 27699-16l 1
13b.Disinfection type: HTH Amount:
, i
Form GW-1 North Carolina Department or Environmental Quality-Division of Water Resources Revised 6-6-2018