GW1-2023-00414_Well Construction - GW1_20230103

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RECORD (GW 1) For Internal Use Only:
WELL CONSTRUCTION
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I.Well Contractor Information:
RANDY OWNBEY
1 WATER ZONES I ,
Well ContmctorName PRR OM TO DESCRIPTION
3214A 389 ft- 390
NC Well Contractor Certification Numbcr ft• ft.
AIR DRILLING I N C '15.OUTER CASING for multi-cased6 'ells OR LINER if a licable
FRO\I TO DIAMETER I THICKNESS MATERIAL
Company Name 0 ft• 63 ft 6 1 in. PVC
325999 •16:INNER CASING OR TUBING' cotbcrmal closed-loop
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well constriction permits(i.e.U/C,County,Slate,Vadmtce,etc.) ft. ft. in.
3.Well Use(check well use): n. ft. f in.
Water Supply Well: 17;SCREEN
❑Agricultural FROM TO DIAMETER S1.0'rSI%F: 1'IIICKNtSS vIA'1'F:RIAI,b ❑Municipal/Public tt. tt. in.
❑Gcothennal(Ileating/Cooling Supply) CJResidential Water Supply(single)
ft. ft. in. '
❑Industrial/Commercial El Residential Water Supply(shared)
18.GROUT '
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD S AMOUNT
Non-Water Supply Well: 0 tt. 20 ft- GROUT POURED
❑Monitoring ❑Recovery ft. ft.
Injection Well:
❑A uifer Recharge Groundwater Remediation ft. ft.
❑Aquifer Storage and Recovery ❑Salinity Barrier 19. I NDIGRAOVEL PACK it applicable)
MATERIAL EMPLACEMENT METIIOD
❑Aquifer Test ❑Stonnwater Drainage
❑Experimental Technology ❑Subsidence Control ft. rt.
❑Geothermal(Closed Loop) []Tracer 20.'DRILLiNG LOG attach additional sheets if necessary)
❑Geothermal(Hcating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,sall/rock type.grain size,cle.
f`' 53 fl• DIRT
4.Date Well 0
3-11-2022 s)Completed: Well ID# 53 ft• 405 ft- ROCK
5a.Well Location: ft. ft.
GERALD WEEKLY ft. ft. .� ..� ,'a ' ,'—
Facility/Owner Name Facility iDll(ifapplicable) ft. ft. N r
129 PRESSLEY FARM RD,STONY POINT,N.C.28678 ft. ft. —
Physical Address,City,and Zip It. ft.
IREDELL 3795175227 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.Certi tion:
350 48.504 N 810 03.094 W
3/14/2022
6.Is(are)the well(s): ClPermanent or ❑Temporary Signature or Certified Well Contractor Date
Bysigning this form,!hereby cert j•dot the well(s)was(ivere)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15A NCAC 02C.0-100 Well Construction Sranelarek and that a copy
lfthis is a repair,fill out known well construction h formation and explain the nature ofthe (fthis record has peen provided to the well owner.
repair under#21 remarks section or on the back of this faro.
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-i is needed. Indicate TOTAL NUMBER of wells (add'Scc Over,in Remarks Box).You niay also attach additional pages if necessary.
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:405
For mudliple wells list all depths((afferent(ara iple-3 a 200'otd 2@100) (f t) 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),
!Porter 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(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12•Well construction method:(i.e.auger,rotary,cable,direct push,etc.) 24c.For Water Supply and Open-Lo I Geothermal Return Wells•Copy to the
county environmental health department of the county where instailcd
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producine over 100,000 GPD• Copy to DWR,CCPCUA
13a.Yield(gpm)2 it Method of test AIR Perm Program, 1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount:
Form OW-I 7
North Carolina Department of Environmental Quality-Division of Water Resources I Revised 6-6-2018