GW1-2023-00425_Well Construction - GW1_20230103

WELL CONSTRUCTION RECORD(GW 1)
For.Internal Use Only: f
I.Well Contractor Information: I
RANDY OWNBEY
'= 14 WATER•ZONES=
Well CongactorName FROM TO . DESCRIPTION
3214A 149 It 150 ft-
NC Well Contractor Certification Number ft ft. I
AIR DRILLING l N C 15.OUTER CASING far malt)easedP,wells ,OR LINER if a livable
FROM TO DIAMETER THICKNESS M1tATERIAL
Company Name 0 ft- 124 ft- 6 in. PVC
16-INNER,CA3ING OR TUBING' 'eotherMal'closed=loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(t e.UIC,County,State,Variance,etc.) ft ft. in,
3.Well Use(check well use): ft. & in.
Water Supply Well: :17.SCREEN-. ..
❑A ricultural FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL g ❑MunicipaUPublic ft ft. lin.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) ft ft
dlrri ation ❑Wells>100000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 IL 20 ft- GROUT POURED
❑Monitoring ❑Recovery ft tt.
Injection Well:
❑A uifer Recharge ❑Groundwater Remediation ft. ft.
❑Aquifer Storage and Recovery ❑Salinity Barrier 19.SAND/GRAVEL PACK if a livable
FROM1f TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage ft fa
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer 30:DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under Remarks) FROM TO DESCRIPTION color 6nrdness,soiVrock a grain 3 err
0 ft 114 ft- DIRT '
4.Date Well(s)Completed: 1 4-2022 Well ID# 114 ft• 165 ft ROCK
5a.Well Location: ft. ft {_
JESSIE ONEKHENA ft ft
Facility/Owner Name Facility ID#(if applicable). ft ft 1 I,1 1i IN
220 BAY CROSSING,MOORESVILLE,N.C. 28117 ft %
Physical Address,City,and Zip ft ft.
I RED ELL 21.REMARKS,
County Parcel Identification No,(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certify on:
350 38.149 N 80° 53.377 W
1/4/2022
6.Is(are)the well(s): ClPermanent or ❑Temporary Signature ofCertified Well Contractor Date
By.signing thisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or It No 15A NCAC 02C.0100 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 the 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 havingthe 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'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 165 (ft.)
For multiple wells list all depths ifdierennt(example-3 a 00'and 2@I00') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 40 (ft) 249. 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
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 24c.For Water Su I and Open-Loop Geothermal Return Wells:Copy to the
etc.) county-environmental health department or the county where instal ed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 1"0"GPD Copy to DWR,CCPCUA
13a.Yield(gpm) 50 Method of test: AIR Permit Program,1611 MSC,Raleigh,NC 27699-161 I
13b.Disinfection type: HTH Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018