GW1-2023-00505_Well Construction - GW1_20230104

WELL CONSTRUCTION RECORD (GW-1) for Internal Use Only: p
I.Well Contractor information: I
RANDY OWNBEY- - I
14.WATER ZONES
Well Contractor Name FROM 1.0 DESCRIPiI'ION
3214A 489 rt- 490 ft- f
ft. ft. ;
NC Well Contractor Cerlifncelitn Number
AIR DRILLING I N C 15.OUTER CASING for multi-cased tr'ells OR LINER(it a licable
FROM TO WAMETER TIIICKNESS atATFR1AL
Company Name 0 rt. 107 rt• 6 in. gaIV
371387 16.INNER CASING,OR TUBING( eothermal closed-ino
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable tivell construction permits(i.e.U1C,Coln!),State.Pariancc,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. itt.
Water Supply Well: 17.SCREEN
FROM To DIAMETER SLOTSIZE T11ICKNFSS MATERIn1,
❑Agricultural ❑Municipal/Public ft. ft ill.
❑Geothermal(Heating/Cooling Supply) CJResidential Water Supply(single)
ft. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared)
IS.GROUT
01ri-i'atiotl ❑Wells> 100,000 GPD FROM TO MATFRIAL EMPLACF.NIENTMETIIOD S AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. grout POURED
❑Monitoring ❑Recovery h. ft.
Injection Well:
ft. tt.
❑Aquifer Recharge ❑Groundwater Remcdiation
❑Aquifer Storage and Recovery ❑Salinit Barrier 19.SAND/GRAVEL PACK(if a licable)
y FROM TO MATERIAL EMPLACEMCNTMET110D
❑AquiterTest ❑StonnwaterDrainage
❑Experimental Technology ❑Subsidence Control
❑Gcothenttal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiltrack type.grain size,etc.)
0 rt. 97 rt. DIRT
4.Date Well(s)Completed: 09-27-2022 Well ID# 97 (t• 505 tt• ROCK
5a.Well Location:
CODY EAGLE ft. ft. _
Facility/Owner Name Facility iD#(irapplicable) f[. ft. t'"•i S� a `'+s, }
7161 OLD MOCKSVILLE RD,SALISBURY,N.C. 28144 rt. ft.
Physical Address,City,and Zip ft. ft. jAN 0 - 2023
ROWAN 309150 21.REMARKS
County Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one tat/long is sufficient) 22.CerC ,lion
350 44.969 N 800 29.488 W 9/27/2022
6.Is(are)the well(s): CJPermanent or ❑Temporary Signature ofCertifned Well Contractor Date
By signing thisJoran,1 hereby cerl0•that the tvell(s)was(were)constructed in accordance iNth
7.Is this a repair to an existing Well: ❑Yes or I_11No 15A tVCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
f this is a repair,fill out known wet!construction h formation and explain the nature of the of this retard has heen provided to the well owner.
repair under#21 reutarks section or on the hack of this Ruin.
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 mvell construction info
construction,only I GW-1 is heeded. Indicate TOTAL NUMBER of wells (add'See Ovcr'in Remarks Box).You may also attach additional pages if necessary.
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 505 (rt.)
Fortualliple wells list all depths ifdifjcrent(example-3 a,200'rad 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 to Division of Watcr Resources (DWR),
f water level is above rashhS,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
i..Well construction method: 24c.For Water Su ly and Open-Loop Geothermal Return Wells•Co to the
(i.e.auger,rosary,cable,direct push•etc.) UP P Copy
county envtronmeutal 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) 10 l Method of test• a I r Permit Program, 1611 MSC,Raleigh,NC 27199-1611
13b.Disinfection type: I Ith Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2015