GW1-2023-00493_Well Construction - GW1_20230104

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WELL CONSTRUCTION RECORD (GW 1) For Internal Use Only:
I.Well Contractor Information: �
RANDY OWNBEY
A4.'WATER'ZONES_
Well Contractor Name FROM1I TO DESCRIPTION
3214A 289 ft. 290 rr.
NC Well Contractor Certification Number 4 1
AIR DRILLING I N C '95.OUTER CASING,for inditfieased wells'OR LINER if a licable
FROM TO - DIAMETER I THICKNESS MATERIAL
0 ft. 91 rt. 6 I, in.
Company Name pVC
2003�]1 16.INNEW CASING OR TUBING:geothermal closed-loop)_
'-'
2.Well Construction Permit#: J FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Stale,.Variance•etc:) ft. ft.
. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN--'.:
FROM TO DIAMETER ' SLOT SIZE 'THICKNESS MATERIAL
❑Agricultural OMunicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) [!]Residential Water Supply(single)
ft. tt. in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
`:18:GROUT '
❑irri nation ❑Wells>100,000 GPD FRO5I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 tt. 20 t' GROUT POURED
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
uifer Storage and Recovery 19;SAND/GRAVEL PACK if a licablc
❑A
q g ry ❑Salinity Barrier FROM TO MATERIAL EMPLACEM1IENTMETtiOD
❑Aquifer Test ❑Stormwater Drainage ft. tt.
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20:,DRIL'LING LOG'attach uddifionafsheets it necessary.
]Geothermal(Hcating/Cooling Retum) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rack type,grain size,etc.)
0 t'• 81 f'• DIRT
4.Date Well(s)Completed: 3-28-2022 Well ID# 81 tt 305 ft• ROCK
5a.Well Location:
TREXLER CONSTRUCTION
Facility/Owner Name Facility ID#(if applicable)
140 AUTUMN LIGHT RD,SALISBURY,N.C. 28147 JAB
Physical Address,City,and Zip ft. ft.
ROWAN 458DO01 21:REMARKS fl'ili i27na t -r: .:, ti„7J 55:
Count JLta lly Ga - .
Y Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well'field,one]at/long is sufficient) 22.Certi tioni
350 40.103 N 80- 32.522 w 3/28/2022
6.Is(are)the well(s): In Permanent or ❑Temporary Signature ofCcrtified Well Contractor Date
By signing thisforrn,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or [!]No 15A'NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a cap),
If this is a repair,fill out known well constructioil information and explain the nature of the of this record has been provided to the well owner.
repair realer#21 remarks section or on the back of thisforni.
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'Sce 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 multiple wells list all depths ifeli(ferent(erannple-3 a,200'and 2Q100) ( ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 50 (ft.) 24a. For All Wells: Original form jto Division of Water Resources (DWR),
If water level is above casing,use"+•• Information Processing Unit,1617 MSIC,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) 6 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-I North Carolina Department of Environmental Quality-Division of Water Resources I Revised 6-6-2018