GW1-2023-00413_Well Construction - GW1_20230103

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WELL CONSTRUCTION RECORD (GW 1) For Internal Use Only:
I.Well Contractor Information:
RANDY OWNBEY
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-''14.•,WATER'ZONES ,.•,`. .';H i; ..- ' •_ .. _ - ;.
Well Contractor Name FRO,rt TO DESCRIPTION
3214A 309 ft. 310 ft. k
NC Well Contractor Certification Number ft. ft. P
AIRAlp DRILLING INC 'IS.OUTER;GASING:form�lti_coseds,ivells OR`LINERIifa"Itcable,
'V(j fFRO.11 TO DIAMETER THICKNESS MATERIAL
Company Name
ft. 71 ft. 6 in. PVC
324509 I6:INNERCASING,ORTUBiNG `oothermalclosed-too
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well constriction permits(i.e.UIC,Co ity,State,Variance;etc.) ft. ft. in.
3.Well Use(check well use): ft. [t. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER , SL8TSi2F THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public
[]Geothermal(Heating/cooling Supply) ClResidential.Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) Is-'GRJOU
❑i i ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. GROUT POURED
❑Monitoring ❑Recovery
Injection Well:
❑A uifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier 19'SAND/GRAVEL PACK f n lieablc i .
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StonnwaterDrainage
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) oTracer 20.DRIL'LING•LOG(attach additiomiustieets if uecessar )
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soilfrock type.graln size,etc.
p, ft' 61 ft DIRT
4.Date Well(s)Completed: 3-10-2022 well ID# 61 ft 325 ' ft ROCK
Sa.Well Location:
RANDY MELVIN ft.
Facility/Owner Name Facility ID#(ifapplicable) ft,
150 SHADY COVE RD,TROUTMAN,N.C. 28166 ft. ft. JAN
Physical Address,City,and Zip ft. ft.
IREDELL 4730712422 21.REMARKs
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.C ]eatio
350 39.459 N 80° 53.402 W 3/10/2022
6.Is(are)the well(s): ClPermanent or ❑Temporary Signature of Certified Well Contractor Date
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By signing this form,I hereby certi•that the'
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eIlls)ivas(were)constructed in accordance ivith
7.Is this a repair to an existing Well: ❑Yes or �No 15A NCAC 01C.0100'or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis 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 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 1 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: 325 ft.
For multiple wells list all depths ifdi,/ferent(erample-3 r@i 200'and 2@100) ) Submit this GW-1 within 30 days of well completion per the following:
10.Static,water level below top of casing:40 ft. 24a. For All Wells: Original form to Division of Water Resources (DWR),
!!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 DWIt,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 department of the county where installed
FOR WATER SUPPLY WELLS ONLY: p 24d.For Water Wells producing oveIr 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) u Method of test:
AIR 'Permit Program,1611 MSC,Raleigh,NC27699-1611
13b.Disinfection type: u LITU Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 6-6-2018
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