GW1-2023-00492_Well Construction - GW1_20230104

WELL CONSTRUCTION RECORD (GW 1) For Internal Use Only: 1
1,Well Contractor information:
RANDY OWNBEY
Well Contractor Name FROM 't'O DESCRIPTION -
3214A 229 ft- 230 ft. t
ft. ft.
NC Well Contractor Certification Number I
AIR DRILLING I N C 15.`OUTER CASING for multi-ctised'wells OR LINER if applicable)
FROM TO DIAMETER i THICKNESS MATERIAL
Company Name 0 ft- 68 ft- 6 1 In• PVC
2.Well Construction Permit#:
328573 16.INNER'CASING.OR TUBING cothermal closed-loo
FROG[ TO DIAMETER THICKNESS MATERIAL
List all applicable well catstruction perntits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. it. in.
Water Supply Well: 17.SCREEN
FRO\I 'to DIAMETER SLOT SI%E '1'FIICKNESL.
❑Agricultural ❑MunicipaUPublic S MATERIAft. ft. in.
❑Geothermal(Heating/Cooling Supply) [!)Residential Water Supply(single)
ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
`'18.'GROUT'.
❑Irri ation ❑Wclls>100,000GPD FROdI �20ft-
MATERIAL EMPLACEMENTMETIIOD&AMOUNT
Non-Water Supply Well: 0 rutGROUT POURED
❑Monitoring ❑Recovery
Injection Well:
❑A uifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinit Barrier '19.SAND/GRAVEL PACK if a licablc
y FROSI TO MATERIAL EMPLACEI1fENTMET1iOD
❑Aquifer Test ❑StormwaterDrainage ft. ft,
❑Experimental Technology ❑Subsidence Control ft. rut.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessar'
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color hardness soil/rock type,grain size,etc.)
0 a. 58 rut. DIRT
4.Date Well(s)Completed: 3-30-2022 Well ID# 58 ft• 245 ft. ROCK
5a.Well Location: ft. ft. t7-.-z
DAVID SMITH rut• 1-4 't 1 -v.
Facility/Owner Name Facility iD#(ifapplicablc) ft. ft. AN O F 2023
513 SNIDER ST, SALISBURY,N.C. 28144
Physical Address,City,and Zip �v��e'C31u.�u•h
ROWAN 052209 721.REMARKS
County Parcel Identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one 1ethong is sufTieient) 22.Certif on:
350 41.341 N 80° 24.360 W
6.Is(are)the well(s): InPermanent or ❑Temporary Signaiure ofCert fied Well Contractor Date
By signing this form,1 hereby certify dmt the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or IJNo 15,4 NCAC 02C.0100 a'15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and arplain the nature of the of this record has heen provided to the well owner.
repair under#21 remarks section at-on the back of this farm,
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'Sec Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 245 ft.
For multiple wells list all depths ifdierent(araniple-3@200'and 2 tt,100') (ft.) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 30 (ft.) 24a. For All Wells: Original forrim to Division of Water Resources (DWR),
f water level is above casing,use '+^ ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6 24b.For Injection Wells: Copy to IDWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
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12•Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells Copy to the
(i.e.auger,rosary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing v er 100 000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 12 Method of test:
AIR Permit Program,1611 MSC,Raleigh,NC 27699-1611
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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 Revised 6-6-2018