GW1-2023-00426_Well Construction - GW1_20230103

WELL CONSTRUCTION I21PC'ORD (rnV 1
For Internal iJsC Only:
I.Well Contractor lilt'ornlalion:
RANDY OWNBEY
Well Cocuractor Name r14-NVATER ZONES'I'CT DIiSCHI P'1•IUN3214A 190 NC\Vol'CunlraClor Ccrtitientims Number ft ft.AIR DRILLING INC ER CASING I'ot ntniti-case((;wells)OR LINER(it'_ DIAaUTE.1 - THICI:N7i5S
Company Name p rl, g� ft, g I Inc.-- PVC - --
2022-9901 16.INNER CASING OR TUi31NG eothern at closed-loo ) ---—
2,Well Colshnctiou Pcrmitf/: r�RU11 fU' U1,\171iTRn_ Imc�;Nl:Ss �tnrrat,u_
List u!I applicable Well can.etvcuioll permiis(i.e.U/C,Caiutp,Srrcre-, Varirmec,cic.j fl - ff. --- in. --- '-
3.Well Use(elneel(ll'ell usC): fL fL in. -
Water Supply Well; rSGR'O
Ef�Agriculturall i I'0 ER SLOTSI•rr THICKNRSS A1,crrAUAl❑MunicipaUl ublic ft. ft.CJGcothernlal(heating/Cooling Supply) I'1ResidCrtial Water Supply(single) ft' ft. In.
(=llndushial/Commercial ❑Residential WaterSupply(shared)1-11rrigalion UT
❑Wells> 100,000GPD ritosl 7o nLk_TE , UYIPLACI_a11:Y1':\i1STilOUsnnlouNr
Non-Water Supply Well: 0 f'' 20 f'• GROUT POURED
Clivlonitoring Glltecovery ft
Injection Well: _
f_]Aquifer Recharge 001-01,11dwaler Renledintion It. ft.
11Aqui 1•er Storage and Recover 19.SAND/GRAVEL PACK if a))Iicublc) --
Y tJStllinityl3arricr f110mt —1`o alnrtaitlnl• enrrl.,uaausNr,yn•:rlu)u
t_IAquilbr•fist Mtornlwatcr Drainage ft. --
1-1Hxperinlental Technology CISubSidence Control ft. ft. — — -------
r(Geothermal(Closed Loop) ClTrncer 20.DRILLING LOG nttnch a(lditional sheets if necessary)
I.IGeothermal(lieating/Cooling Return) :10ther(explain under#21 Rcmarks) 1 ROai ro oes(:IttPI ION(color,11,nm+ess,soiyrock iyLgrntn sire,ry_)
p fl, 85 rt. DIRT _
4.Date Well(s)Completed: 12-5-2022 Well IDII 85 r' 205 '' ROCK ---
5a.Well Location: --
DONALD LUNSFORD
P;,uility/Owner Name Facility lDll(itspplicable) ft. IL JAB s -
120 PINE STATE RD, TROUTMAN,N.C. 28166 —ft-
Physical
Physical Address.City,and"Lip ft. fL 1f1;Gii c a�
4741138609 "%N'27QG
IREDELL z1.REMARI<s —
Cou"ty Parcel identification No.(PIN)
5b.Latitude and longitude ill degrees/milllrtes/seconds or decimal degrees: --
Orwell lield,one Ita/long is sufficient) 22.Certlt- on: — -i-----
350 41 .783 N 80- 52.787
12/5/2022
fi,IS(al•e)the We11(s): ClPermanent o- 1-71'emporary Signature ol'Ccrtifiud Wcll Contrnclor p;,ie ^--
7.Is this a 1'L'p:lil'to an C4v signing thi.r•%w•rn,1 her eGP cerri/i diar ncu,rci!(sJ sruv(mere)Caran�o-led in urrarduncr+rich
xistillg lyell: I]Yes of MNo 15.4 AICAC 02C'.ol oo or 15A AICAC:02C.0.?00 INe/Cunstrucviun Suuulardc roan clot a rapt
//'this is it repair.Jill our lyt011,11 well construction ill rnluliwl runt!eeplain(he nature of th« a/'tl+ia recore/nuns been pror/ded to the melt uumw.
repair under;12/reauarky Section or on the back(J'this forty.
23.Site(ling'-anl o•additional Well cletafls:
S.For Geoprobe/DPT o•Closed-Loop Geothermal Wells having tLC same You May use the back of this page to provide additional well construction info
conslnlclion,Wily I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary
drillcd:________
24.SU131mi rTAL INSTRUCTIONS
9-Total Well depth below land surface: 205 (ft.)
Fur ntdtiple wells list till depthsiJ'rlillcrent(eyuulple-3 rr)200'nnrll n,Jf)T) Submit this GW-1 within 30 days of hell completion per the following:
10.Static water level below top of casing: 40 (fl.) 24a. For All Wells: Original form to Division of Wa(Cl- Resources (DWR),
Y'lraler lovol is whore Casing,use' t" fllfornintioll llroO CsSIng IIOit, 1617 MSC,Raleigh,NC 27699-1617
i
I1.Borehole diameter: 6 (in.) 24h. For]njcctio) Wells: Copy to DWIZ, Underground injection Control (IU(:)
Program, 1636 MSC,Raleigh,NC 27699-1636
12,Well construction method:
(i.e.auger,routry,cable,direct push,etc.) 24e.For Water Su )I f ply and Open-Loo Geothermal Return Wells.Copy to the
counly environmental health departlnCnl o llle County Where installed
h( R WATER SUPPLY WELLS ONLY: 24d.For!Pater Mlefls producing over 100,000 GI'D: Copy to DWIZ,CCPCUA
13a.Yield(gplll) 25 M011od Of test: AI R Pernut Program, 1611 MSC,Raleigh,NC 27699-1611
131).Disinfection type: HTH Amount:
form UW-I North(:arulinu Dcparuncnl ol'Gnvironnlcnud Ouulily-
Division of'Water Resources Revised 6-6- 015