GW1-2023-00541_Well Construction - GW1_20230104

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.*c(1 Contractor information:
RANDY OWNBEY
I �
14.WATER ZONES
Well Contractor Name FRO31 •1.0 DESCRIPTION
3214A 529 ft. 530 ft- I
ft.
NC Well Contractor Certification Number R.
I5.OUTER CASING for.multi-eased wells)OR LINER
AIR DRILLING I N C if a rlicahle)
FRU\I TO DIAdtF,TER TIIICKNESS NATF,RL\L
ft. ft. in.
Company Name
E H W22-01860 16.INNER CASING OR TUBING cothermal closed-loon)
2.WCII Construction Permit#: FROM TO DI\\tETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Fariance,etc.) 0 ft- 40 ft. 6 in. PVC
3.Well Use(check well use): ft. ft. I in.
Water Supply Well: 17.SCREEN
FROM •ro DIAatE'rER SLOTSI•r.E rulCKuess MATFRlnl.
❑Agriculturd ❑MunicipaUPublic rt. ft. in.
❑Geothermal(licating/Cooling Supply) MResidential Water Supply(single) ft.
❑industrial/Conuncrcial ❑Residential Water Supply(shared) 18,GROUT
❑irri gation ❑Wel ls>100,000 GPD FROM I TO MATERIAL EMPLACEM ENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 fL GROUT POURED
❑Monitoring ❑Recovery ft. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation R. ft.
❑Aquifer Storage and.Recovery ❑Salinit Barrier 19.SAND/GRAVEL PACK if n licablc
y FRO\I TO MATERIAL EMPI CEMENTMF.TIIOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(1-leating/Cooling Return) ❑Other(explain under#21 Remarks) FROM I TO DESCRIPTION(color,hardness,solitrock Iv ne,grain size,etc.
0 ft. 30 ft, DIRT
4.Date Well(s)Completed: 06-09-2022 well ID# 30 ft• 545 ft• ROCK
5a.Well Location: ft. ft.
RADKE PROPERTIES/HICKORY WELL ft. ft.
Facility/Owner Name Facility iDII(ifapplicable) ft. ft. „
2250 IVEY CHURCH RD,MAIDEN,N.C. 28658 ft. rt. -
1
Physical Address,City,and Zip ft. ft. X, 71: l
LINCOLN 25693/25696 21.REMARKs
County Parcel Identification No.(PIN) I
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one W/long is sufficient) 22.Certif ion::
350 32.059 N 81 ° 08.460 W ) 1 6/9/2022
6.Is(are)the well(s): Mllermanent or Li emporary Signature of Certified Well Contmclor Date
By slguing thisform,l hereby cert(&that the wellft)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or IlNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 if'ell Construction Stanclar(h and that a copy
//7his is it repair,Jill out known well construction iri/brnration and erplain the nature o/iha q(this record has been provided to the well owner.
repair under k21 remarke section or on the back of this form.
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-1 is needed. Indicate TOTAL NUMBER of wells (add'Sce Over'in Remarks Box).You may also attach additional pages if necessary.
dril Icd:
24.SUBMITTAL INSTRUCTIONS
9,Total well depth below land surface: 545 (ft')Fornitlple Submit this GW-1 within 30 days of well completion per the following:
uu ur.!!s!is(fill depthsif di(fcrenl(example-3 to 00'and 2�i1100')
10.Static water level below top of casing: 70 24a. For All Wells: Original form!to Division of Water Resources (DWR),
1J'u•oer level is above rasing,use"+•• Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617 I
11.Borehole diameter: 6 (in,) 24b.For Injection Wells: Copy to lJWR, Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
1 .Well construction method: 24c.For Water•Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.augur,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(gpnr) 0 Method of test: AIR
Fermi(Program, 1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018