GW1-2023-00561_Well Construction - GW1_20230104

D (GW 1) For Internal Use Only:
WELL CONSTRUCTION RECOR
1.Well Contractor Information:
RANDY OWNBEY
MOUTERCASING
NES- _
Well Contractor Name DESCRIPTION
3214A ft- 0 ft.
ft.
NC Well Contractor Certification Number
AIR DRILLING I N C ING for multi-cased wells)OR LINER if a licable DLWIETER TIIICIENRli aATERIAL
fi. 6 'In.
Company Name PVC
16.INNER CASING OR TUBING eothermal closed-too
2.Well Construction Permit#: FROd1 TO DIA51ETER. J THICKNESS MATERIAL
List all applicable ivell construction permits(i.e.UIC,Cortnly,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
F'RO\I 't'O DIAMETER SLOTSIZE I THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.i
❑Geothermal(Heating/Cooling Supply) L9Residential Water Supply(single)
ft. ft. in.'•
❑Industrial/Con)mcrcial ❑Residential Water Supply(shared) ;
IS.GROUT J,
❑Irrl ation ❑Wells>100,000 GPD FRO TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: M 0 ft• 20 ft. GROUT POURED
❑Monitoring ❑Recovery ft. R.
Injection Well:
❑A uifer Recharge f. ft.❑Groundwater Remediation❑Aquifer Storage and Recovery ❑Salinity Barrier' 19.SAND/GRAVEL PACK(if a licable
FROdI I TO MATERIAL EMPLACEaIENTMETHOD
❑Aquifer Test ❑StornlwaterDr•ainage ft. ft.
❑Experimcntal Technology ❑Subsidence Control rt. ft.
❑Gcothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothennal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soillrock type.grain size,etc.)
p fL 65 f' DIRT
4.Date Well(s)Completed: 09-06-2022 Well ID# 65 ft. 305 ft• ROCK ,
5a.Well Location: ft. ft.
ROBERT THRIFT ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
5061 LAUREL HAVEN AVE,MORGANTON,N.C. 286554 ft. ft. r l�
Physical Address,City,and Zip ft. ft,
BURKE 15990 21.REMARKS �'�� ✓Vaar f'�
County Parcel identification No.(PiN)
5b.Latitude and longitude in degrees/Ininutcs/seconds or decimal degrees:
(if well field,one[at/long is sufficient)
22.Certifi n:
350 40.290 N 81° 34.273 W 9/6/2022
6.Is(are)the well(s): C1Permanent or ❑Temporary Signature ofCeni ed Wcll Contractor Date
Dy signing this fo m,,1 hereby certify,that the Ivel/(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or InNo 15A NCAC 02C.0100 at-15A NC4C 02C.0200 Well Construction Standards and that a copy
!This is a repair,Jill out known well construction information and atplain the nature of the q/1'his record has been provided to the well owner.
repair under 1121 remarks section or on the back of this fornn.
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.
Far•multiple wells list all depths iftli erent(arample-3 a 200'and 2@100) ( ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 70 ft 24a. For All Wells: Original form to Division of Water Resources (DWR),
If i aler level is above casing,use•'+^ ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1611
In.'
11.Borehole diameter: 6 24b.For(in.) lection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24a For Water Supply and Open-I,00p'Gootherntal 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: I
24d.For Water Wells producing over 1'00 0"GPD Copy to DWR,CCPCUA
13a.Yield(gpm) 10 1 u Method of test:AIR Permit Program, 1611 MSC,Raleigh,NC 27699-16l l
13b.Disinfection type: HTH Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-201 S
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