GW1-2023-00554_Well Construction - GW1_20230104

WELL CONSTRUCTION RECORD (QW-1) For Internal-Use Only;
I.Well Contractor Information:
RANDY OWNBEY
Well WATER-ZONES Name
FROM TO DESCRIPTION'
3214A 249 ft- 250 ft.
NC Well Contractor Certification Number ft.
,'IS;,OUTER:.CXSING"Iform'fllti-'6fi§idt.welis R(ifappllcable
AIR DRILLING INCFR0,NI TO I DIAMETER I I THICKNESS .
MATERIAL
Company Name 0 f- 85 ft- 16 1, in. GLAV
I
16-'. . - , ermal clo-sed'Ito'2.Well Construction Permit#: 09-2021 ER-CASING OR TUBING: eotif
-157858 FROM TO DIAMETER : THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. I in.
3.Well Use(check well use). ft. R. f in.
ater Supply Well: 17;'_SCREEN,',"
IIV
DAgricultural
FROM TO DIAMETER SLOTSIZE THICKNESS MA T I ERIAI DMunicipal/Public in.
111Gcothermal(Heating/Cooling Supply) InResidential Water Supply(Single)
01ndustrial/Commercial ft. ft. in.
ElResidential Water Supply(shared)
DIrrigation
OWells>100,000 GPD FROM TO
Non-Water Supply Well: MATERIAL EMPLACEMENT METHOD&AMOUNT
13Monitoring DRecovery 0 20 OUT POURED
Injection Well:
0 Aquifer Recharge ElGroundwater Remediation ft ft.
DAquifer Storage and Recovery DSalinity Barrier A9._SAND/GRA if applleablO_
FROM
_EE2_1 TO MATERIAL
EMPLACEMENT METHOD
DAquifer Test D Stormwater Drainage ft. ft.
OExperimental Technology 0 Subsidence Control rt t
,EIGcothermal(Closed Loop) DTraccr f— 7
20;DRIL- G�L'OE'(attach addit! 6l,sheets if necessary):
DGeothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM �TO DESCRIPTION(color,hardness,soil/rock type.umin size,etc.)
4.Date Well Completed: 3-4-2022 0 75 DIRT
Well ID# 75 ft' 265 ft ROCK
Sa.Well Location: ft. — ft.
BLUEFIELD BUILDERS
Facility/Owner Name Facility ID#(if applicable) ft. ft.
4990 SLANTING BRIDGE SHERRILLS F0RD ,N.C.28673 ft. ; ft. . JAN 0 4 _10Z3
Physical Address,City,and Zip ft. ft.
Lln;,i
CATAWBA 460604831336 21^.REMARKS'-7� 7—
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certi ion:
360 33.219 N80- 59.220
W w 3/4/2022
6.Is(are)the well(s): [!]Permanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the n611(s)was(were)constructed fit accordance with7.Is this a repair to an existing well: DYes or InNo 15A NC,4C 02C.0100 or 15A NCAC 02C.0.200 Well Construction Standards and that a copy
If this is a repair,fill out 1010svit well construction in and explain the nature of the of this record has peen provided to the well tinvner.
repair tinder#21 reniarkv section or on the back of this form. i
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 toipr I bvide additional well construction info
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells (add'Scc Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 265
For multiple wells list all depths if different(example-3@20-0 and 2@100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 20 24a. For All Wells: Original form to Division of Water Resources (PWR),
trivater 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 MR' Underground Injection Control(IUC)
12.Well construction method: Program, 1636 MSC,Raleigh,NC 2761 9-163 6
(i.e.auger,rotary,cable,direct push,ctc.) 24c.For Water Supply and Open-Loop Geothermal Return Copy to the
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells Eroducing over 1000 000 GPD: Copy to DWR,CCPCUA
producing 13a.Yield(gpm)200 Method of test:AI R Permit—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