GW1-2023-00491_Well Construction - GW1_20230104

WELL CONSTRUCTION RECORD (GW 1) For Internal Use Only:
1.WoU Contractor Information:
RANDY OWNBEY
14.WATER'ZONES',,
Wc1lContractorName FROM TO DESCRII"PION
3214A 287 ft• 288 ft•
ft.
NC Well Contractor Certification Number
A I R DRILLING I N C ='15i OUTER CASING for'multi-casedlwclls OR-LINER if a Ucable .
FR051 TO 'DIAMETER THICKNESS MATERIAL.
Company Name 079 ft fr' 6 j 1"' PVC
367722 '16.1NNER CASING ORTUBING eotharmalclosed-foo21
2.Well Construction Permit#: FROM TO DIAMETER. THICKNESS _- MATERIAL
List all applicable well coastntction permits(i.e.UIC,County,State,l�ariance,etc.) ft• It. ! in.
3.Well Use(check well use): ft. ft.
Water Supply Well: '17.-SCREEN' _
❑A icultural FROM ro DinMUTER st.o•rsir,E ' itucicivrss MnrExtnl,
b't ❑Municipal/Public ft. [t, in.
❑Geothermal(Heating/Cooling Supply) C1Residential Water Supply(single)
ft. ft. In..
❑Industrial/Commercial ❑Residential Water Supply,(sharcd)
,18.GROUT=.
DIrrigation ❑Wells> 100,000 GPD FROM M
TO ATERIAL EMPLACEatENT METHOD&AMOUNT
Non-Water Supply Well: 0 rt• 20 ft- GROUT POURED
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft.❑A uifer Recharge ❑Groundwater Remediation ft.
❑Aquifer Storage and Recovery ❑Salini[ Barrier 19.:SAND/GRAVEL PACK if.a licable '
y FROM TO MATERIAL EMPLACEf1IENTMETHOD
❑Aquifer Test ❑Stortnwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
❑Gcothcrmal(Closed Loop) ❑Tracer .20:DRILLING LOG attach ad'rlitional sheets if necessar)
❑Gcothcmial(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROJI TO DESCRIPTION(color,hardness,soil/rock type,grain slrc;etc.
0 It. 69 ft. DIRT
4.Date Well(s)Completed: 4-8-2022 Well ID# 69 % 305 % ROCK•
5a.Well Location:
CHARLES WICKER it. ft.
Facility/Owner Name Facility iD#(ifapplicable) tt• ft. I n G
2023
235 RUFTY CT, SALISBURY,N.C. 28144 tt. 1H
Physical Address,City,and Zip It. ft. 1RiDi i3 3i + h.'�•.r s'.::: L41+
320256
ROWAN :21s REMARKS''`-� � ,-
County Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one ladlong is sufficient)
22.Ccrt' anon:
350 43.022 N 80- 29.009 W
4/8/2022
6.ls(are)the well(s): InPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance with
7.IS this a repair to an existing well: ❑Ycs or LINO 15A NCAC 01C.0100 or 15A NCAC 01C.0100 Nell Constrtrcliat Smndarrly and that a copy
Ifthis is a repair,fill our known well construction information and explain the nature ofthe ofthis record has been provided to the well owner.
repair under#21 reamrkv section or on the back of this fans.
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 I GW-I 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.Total well depth below land surface: 305 (ft.)
For nut/tiple wells list all depths ifdierent(aranple-3@200 and 1 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 fomi 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,etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: I
24d.For Water Wells producing over 100,000 GPD• Copy to DWR,CCPCUA
13a.Yield(gpm) 5 Method of test:AIR Permit Program,1611 MSC,Raleigh;NC 27699-1611
13b.Disinfection type: HTH Amount:
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Reviscd 6-6-2018
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