GW1-2023-00416_Well Construction - GW1_20230103

WELL CONSTRUCTION RECORD(GW 1)
For Internal Use Only:
I.Well Contractor Information: I .i
RANDY OWNBEY
'14;WATE R•ZONES' ),
Well Contractor Name FROM 'I'O DESCRIPTION
3214A 249 ft- 250 ft-
NC Well Contractor Certification Number ft. ft.
AIR DRILLING I N C 15:OUTER CASING for multi-cased well§ OR;LiNER if a licable
FROM TO DIAMETER THICKNESS 11tATERIAL
Company Name 0 ft. 57 rL 6 i" PVC
324959 16;INNER CASING OR TUBING' eothermat closed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construct'"permits 0.e:UIC,County,State,Variance,eec.) ft. ft. In.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: '17 SCREEN:
❑Agricultural FROM TO DIAMETER SLOT sILF. THICKNESS MATERIAL
❑MunicipaUPublic ft. ft. in.;
❑Geothermal(Heating/Cooling Supply) I_nResidential Water Supply(single)
ft. ft, in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
IS.-GROUT
❑ n g ate ❑Wells>100,000 GPD FRO\I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 It' 20 rt. GROUT POURED
❑Monitoring ❑Recovery ft. tt.
Injection Well:
❑Aquifer Recharge .❑Groundwater Remediation ft. ft.
" 19.-SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery '
❑Salinity Barrier FRO\I TO MATERIAL EMPLACEMENTNI IIOD
❑Aquifer Test ❑StonnwaterDrainage rt• ft.
❑Experimental Technology ❑Subsidence Control
❑Gcotilcrmal(Closed Loop) ❑TraceC "20-DRILLiNG LOG attach additional.sheets,if necessary)
❑Geothermal(Hcating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
p rt. 47 rt. DIRT
4.Date Well(s)Completed: 3-2-2022 Well ID# 47 It' 265 ft- ROCK
Sa.Well Location: ft. ft.
ALLAN WOOD/CORBIN WATFORD
Facility/Owner Name Facility iD#(if applicable) ft. ft. E N= ,PT*
4926 HARMONY HWY HARMONY,N.C. 27020 rt. rL
r
Plhysical Address,City,and Zip ft. ft.
IREDELL 4883-09-1820 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:.
(if well field,one]at/long is sufficient) 22.Ce1't' tion: �
• 3/4/2022
360 24.146 N 80° 45.334 W
6.Is(are)the well(s): ClPermanent or ❑Temporary Signature ofCenified Well Contractor Date
By signing this form,I hereby tort f•that theI u•ell(s)was(were)constructed in accordance with
7.IS this a rep:lif to an existing well: ❑Yes or L'INo 15A NCAC 02C.0100 or 15A NCAC 02C,0200 Well Construction Standards and that a copy
lfilds is a repaii,f if out known well construction information and eirplain the nature ofthe of this record has been provided to the well owner.
repair under#' remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe./I)PT 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'Sec Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
24.SUBMITTAL INSTRUCTIONS
9.7total well depth below land surface: 265 (ft.)
For uhrdtiple wells list all depths/fdierenr(ermiiplel-3©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: 40 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
1f water level is above rasing,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-Loop Geothermal Return Wells•Copy to the
county environmetltai health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producine over 100 000 GPD• Copy to DWR,CCPCUA
13a.Yield(gpnl) 10 L� u Method of test:AIR Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount:
Form GW-i North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-201 S