GW1-2023-00418_Well Construction - GW1_20230103

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
RANDY OWNBEY 14:'wATERZONES ..
Well Contractor Name FROM TO UESCRIPI'ION
3214A 729 ft- 730 k
ft. ft. j
NC Well Contactor Certification Number
AIR DRILLING I N C t5.OUTER CASING for multi-eased'wells OR LINER if a licable)
FROM TO DIAMETER THICKNESS hL1TERIAL
Company Name 0 rt. 44 rr. 6 In. PVC
321842 16.INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County State,Variance,etc.) ft. ft. I in.
3.Well Use(check well use): tt. ft. in.
Water Supply Well: 17.SCREEN
FRONT TO DIAMETER SLOT SIZE '1111CKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. rt. in.
❑Geothermal(Heating/Cooling Supply) L*JResidential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FRONT TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 f' 20 ft- GROUT POURED
❑Monitoring ❑Recovery
Injection Well:
rc. rt.
❑Aquifer Recharge ❑Groundwater Remediation
❑Aq 19.SAND/GRAVEL PACK(if a ' licableuifer Storage and Recovery ❑Salinity Barrier FRONT TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control it. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets it necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 921 Remarks) FROM TO DESCRIPTION(color,hardness,soillrock type.grain size,etc.
0 ft- 34 f'• DIRT
4.Date Well(s)Completed: 2-1 9-2o22 Well 1D# 34 ft. 745 ft• ROCK
Sa.Well Location:
SAMUEL L SCOTT CONST
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
175 CEDAR LAKE DR,STATESVILLE,N.C. 28677
Physical Address,City,and Zip
IREDELL 4736711380 21.REMARKS _ y
County Parcel identification No.(PiN) n a'• _ v
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one lat/long is sufficient) 22.Cer ation-
350 49.380 N 800 53.573 W 2/21/2022
6.Is(are)the well(s): ClPermanent or ❑Temporary Signature of Certified Wc11 Contractor `Date
By signing this form,I hereby cert ,that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or InNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Nell 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 the well owner.
repair under 1121 remarks section or on the back of this foram.
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-I 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: 745 ft.)
For multiple wells list all depths ifdii ferent(erantple-3Q200'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: 60 ft 24a. For All Wells: Original form to Division of Water Resources (DWR),
lfwater 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: 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) Method of test:
AIR Permit Program, 1611 MSC,Raleigh,NC 27699-1 6 1 1
I
13b.Disinfection type: HTH Amount:
Form GW-1 North Carolina Department orEnvironmental Quality-Division of Water Resources Revised 6-6-2018