GW1-2023-00501_Well Construction - GW1_20230104

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WELL CONSTRUCTION RECORD (GW 1) For Internal Use Only:
I.Well Contractor information: i
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RANDY OWN BEY
-14.WATER ZONES i
Well Contractor Name FRO31 T DESCRIPTION
3214A 289 rt• 290 ft.
ft. ft.
NC Well Contractor Certification Number f ,
AIR DRILLING I N C 15.OUTER CASING(for multi-cased wells OR LINER(if a livable
FRO\I TO DIAYIETERI THICKNESS ALITERIAL
Company Name 0 ft 104 ft- 6 i PVC
381818 16.INNER CASING OR TUBING cothernta]closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well conslrnctiwt pernuts 0.e.UiC,County,State,Variance,ere.) ft. ft. in.
3.Well Use(check well use): • ft. ft.
Water Supply Well: 17.SCREEN
FROM DIATF sit TSIrI. THICKNr❑Abr1CnlLUra1 ❑Municipa UPublic Ss MA'I'A:RIAI.
ft,
tt. in.i
❑Geothermal(hleating/Cooling Supply) LhResidential Water Supply(single)
ft. ft. in.
❑industrial/Conmicrcial ❑Residential Water Supply(shared)
18:GROUT
Non-n-waate
❑Non-Water
❑Wells>100,000 GPD FROM TO MATERIAL EMPLACERIENT METIIOD 3�AMOUNT
r Supply well: 0 ft. 20 ft, GROUT POURED
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft•❑A uifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinit Barrier 19.SAND/GRAVEL PACK if a licablc
yarc FROJI TO MATERIAL EMPLACEMENTMETHOD
❑AquiferTesl ❑StorinwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geotlicrmal(Beating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO E
CRIPTION hardness sil/rock lv Ic, rain size,Cie.0 f` 94 fT
4.Date weu(s)Completed: 10-13-2022 We11 1D# 94 f' 305 fCK ;
5a.Well Location: ft. f
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MICHAEL GUILLOTE ft. ft.
Facility/Owner Name Facility iD#(ifapplicable) ft. ft.
575 MT TABOR CHURCH RD, CLEVELAND,N.C. 27013 ft• ft. JAti G.
2023
Physical Address,City,and Zip ft. ft.
ROWAN 555033 21;REMARKS' ifti'Gi:a: I Yf: '?•^ - :� fiid
County Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifivell field,one lat/long is sufficient)
350 41.197 N;80- 44.533 22.Cetti tier:
w 10/13/2022
6.Is(are)the well(s): nPermanent or OTemporary Signelurc of Certified Well Contractor Date
By.signing this forol,1 hereby certif 11ta1 the we110)Islas(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or InNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Melt Construction Standards and that a copy
Ythis is a repair•fill our known Nell construction in%rnmtion and explain the nature of the ttfilds record has been provider/to the well runner.
repair under#21 remarks section or oil the back qf thisfbrnj.
23.Site diagram or additional well(retails:
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-1 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 (fl)
For nuthiple wells list all depths ijdijjcrenr(crmttple-3�200'and 2 a 100') Submit this GW-I within 30 days of well completion per the following;
10.Static water level below top of casing: 40 (ft) 24a. For All Wells: Original form Ito Division of Water Resources (DWR),
If water 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: 24d.For water wells producing over 100 000 GPD• Copy to DWR,CCPCUA
13a.Yield(gent) 15 Method of test:AIR Permit Program, 1611 MSC,Raleigh,NC 27699-1611
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13b.Disinfection t e• HTH
YP • Amount: i
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Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources l
Revised 6-6-2018
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