GW1-2023-00417_Well Construction - GW1_20230103

WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only: !
I.Well Contractor Information:
RANDY OWNBEY
14.,WATER:ZONES
Well Contractor Name FROM=(for
N
3214A 589 NC Well Contractor Certification Number15:'OUTER CASING multi-cased wells OR LINER if a licable
AIR DRILLING INC FROM TO DIAMETER 1 TIIICKNESS MATERIAL
Company Name 0 ft. qg ft. 6 in. PVC
314424 16.INNER CASING OR'TUBING ebtlierma]closed-lo,o
2.Well Construction Permit#: FROM I TO DIAMETER THICKNESS M1iATERIAL
List all applicable well construction perwits(i.e.VIC,County,State,Variance,eta) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: -17:SCREEN
'FROM TO DIAMETER SLOT SIZE TUICKNESS MATERIAL❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) CIResidential Water Supply(single)
ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) ft. in..
18.GROUT
❑Irrigation ❑Wells> 100,000 GPD FROM 1 TO M1IATERIAL EMPLACEMENTMETIIOD.&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. GROUT POURED
OMonitoring ❑Recovery ft. ft.
Injection Well:
❑A uifer Recharge ft. ft.
9 g ❑Groundwater Remediation
❑A uifer Storage and Recovery 19.SAND/GRAVEL PACK if applicable),,
9 g ry ❑Salinity Barrier FROM
TO MATERIAL EMPLACEMENT METIIOD
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additiohal'shects if necessary
❑Geothermal(Heating/Cooling Return) []Other(explain under 421 Remarks) FROM TO DESCRIPTION color,hardness,soiltrock type,grain size,etc.
0 rt. 38 rt• DIRT
4.Date Well(s)Completed: 2-16-2022 Well ID# 38 rL 605 ft• ROCK
5a.Well Location:
PEACHTREE RESIDENTIAL ft. ft. ''"'"
Facility/Owner Name Facility ID#(if applicable) ft. ft '
112 COPPER PINE LOT#4,DAVIDSON,N.C. 28036 rt. ft.
Physical Address,City,and Zip ft. ft.
IREDELL "zt.REMARKs
4664861808
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Iat/long is sufficient) 22.Certifica
350 30.513 N 800 47.125 w 2/17/2022
6.Is(are)the well(s): IJPermanent or ❑Temporary Signature ofCcrtified Well Contractor Date
By signing this,form,I hereby certify that the well(s)was(were)constructer/in accordance with
7.Is this a repair to an existing well: , ❑Yes or CJNo 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Smndarts and that a copy
/f this is a repair,fill out known well construction information and explain the nature ofthe of this record has beenprovided to the well owner.
repair uirder 1121 reinarks 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'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 605 (ft.)
For multiple wells list all depths ifdifferent(example-3(_a1200'and 2 tt 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),
/fwaterlevel is above casing,use +^ ( ) Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
II.Borehole diameter: 6 (in.) 24b.For Injection Wells: Copy to DWR, Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
i..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: 24d.For Water Wells producing over 100 000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) 20 Method of test: AIR Permit Program,1611 MSC,Raleigh,NC 276 99-1 6 1 1
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13b.Disinfection type: HTH Amount:
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 6-6-2018
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