GW1-2023-00415_Well Construction - GW1_20230103

WELL CONSTRUCTION RECORD (GW 1) For Internal Use Only:
I.We11,Contractor Information:
RANDY OWNBEY I '
s14.MATERZONES.
Well Contractor Name FROM TO DESCRIPTION
3214A 489 ft- 490 ft. I i
ft. ft. `
NC Well Contmctor Certification Number 1
AIR DRILLING I N C 15:OUTER CASING:for multi-cased.ivelis OR•LiNER ifa licable
FROJI TU DIAMETERI THICKNESS hiA7 EIUAL
f p t. 88 ft.
Company Name 6 � PVC
319380 '1G:'INNER CASING:OR BINGIaebtliernial closed-loos•
2.Well Construction Permit#: FROM TO DIAMETER - THICKNESS NIATERiAL
List all applicable well Construction permits(i.e.UIC,County,State, Variance.etc.) it• ft. in.
3.Well Use(check well use): it. ft. , in.
Water Supply Well: "17.SCREEN`. - =
❑Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Municipal/Public ft. R, in.
❑Geothermal(Heating/Cooling Supply) C1Residential Water Supply(single)
ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
• ,iS:GROUT .•� "-
❑Irri ation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: p ft. 20 ft- GROUT POURED
❑Monitoring ❑Recovery rt. ft.
Injection Well:
i -
OAquifer Recharge ❑Groundwater Remediation ft. ft.
❑Aquifer Storage and Recovery ❑Salinit Barrier 19:SAND/GRAVEL PACK if a" licable
y FROM TO MATERIAL EMPLACEMENT METIIOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer "20.DRILLING LOG,attach additibbal sheets if necessar•
[]Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FRONI TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.
0 f`• 78 f`• DIRT
4.Data Well(s)Completed: 3-8-2022 Well ID# 78 ft• 505 ft• ROCK
5a.Well Location:
LAKEMIST HOMES it. ft. <:.a'a.v- `i�rR ,_
Facility/Owner Name Facility ID#(ifapplicable) ft• ft. JAIV 9
144 RYLEIGH DAN PLACE, MOORESVILLE,N,C. 28117 ft. ft. — `
Physical Address,City,and Zip ft. ft.
IREDELL 4654780931 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.Certific
35031.999 N 80° 49.315 W 3/8/2022
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing Ibis form,l hereby certify Iltat the'well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or CINo 15A NCAC 02C.0/00 or 15A 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 Ilia 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 heeded. 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:505 ft.
For multiple wells list all depths ifdii ferent(eranrple-3@200'and 2@I00) ( ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 50 it 24a, For All Wells: Original form to Division of Water Resources (DWR),
Ifwater level is above casing,use"+^ ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
I
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11.Borehole diameter: (in.) 24b.For Injection lection Wells: Copy to DWR, Underground Injection Control(iUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:
(i.e.auger,rota 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
g ry,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
15 .AIR Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test. I
13b.Disinfection type: fu TH Amount:
i
Form GW-i North Carolina Department of Environmental Quality-Division of Water Resources
Revised 6-6-2018