GW1--00540_Well Construction - GW1_20240118

WELL CONSTRUCTION RECORD GW-1I Print Form
� ) For Internal Use Only:
1.Well Contractor Information: •
RANDY OWNBEY
14,WATER ZONES I
Well Contractor Name FROM1'U DESCRIPTION
3214A 709 ft. 710 Il• I
ft. ft.
NC Well Contractor Certification Number
AIR DRILLING INC 15.OUTER CASING(for multi-cased wells)OR LINER(If ap livable)
FROM TO DIAMETERI THICKNESS MATERIAL.
Company Name 0 ft. 77 ft. 6I in. PVC
245874 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. U/C,County.State, Variance,etc.) fh D. i in.
3.Well Use(check well use): • ft. ft. I in.
Water Supply Well: 17.SCREEN i
A fICUhUI'al FROM TO DIA5Its-I'ER! SLOT SIZE TlICKNI•ss MATERIAL
g OMunicipal/I ublic ft. ft. lin:
Geothermal(Heating/Cooling Supply) [Residential Water Supply(single) :
Ct, ft. in:
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EnIPi„\CEMEN'rMF,TIIOD�,\\10UN'r
Non-Water Supply Well: 0 rl. 20 ft. GROUT POURED
Monitoring Recovery ft. ft.
Injection Well:
,Aquifer Recharge It. fL
b' DGroundwatcr Remediation
Aquifer Storage and Recovery19.SAND/GRAVEL PACK or applicable)
DSalinity Barrier FROM TO MATERIAL Iinl l'L.\CEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft. _
Geother Experimental Technology
logy QlSubsidence Control ft. tt.
Geothermal(Closed Loop) ❑ITracer 20.DRILLING LOG(attach udditiotial sheets If necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DKSCRIP'I'ION(color,hardness,soli/rock type,grain size,etc.)
0 IL 67 rL DIRT,
4.Date Well(s)Completed: 11-1-23 Well IDI/ 67 It• 725 ft' ROCK
ft. ft.5a.Well Location: a o �"jr)
,; a 7 4
MICHAEL YODER ft. ft. o
Facility/Owner Name Facility ID//(ifapplicablc) ft. ft• I , A�l f s ZU2`t
241 CASTLE LANE,MOCKSVILLE,N.C. 27028 IL rt. j Fr 1 -zioa. � jri
cal Address,
I hysi City,and Zip ft. II.
c �CC t t: --
DAVIE 5709887416 21.REMARKS I • -J
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.Certific
350 55.983 N 80° 39.423 W
4.4 1 1—1—23
G.Is(are)c)the wells) X Permanent or [p'1'emporar), Signature of Ccrtif1,d Welt Contractor Date
By signior;this ftn•nt,/hereby ceetifi'that the well(s) tax(were)consirttcicd in ac•c•ordmtcc•
7.Is this a repair to an existing well: DYes or EjNo with 1 SA NCAC 02C.0/00 or ISA NCAC(12C:.0200 Well Construction.Standards and that a
!Phis is a repair.Jill out known tell construction inhumation and explain the nature arthe copy°J'dds recant hos hem prowled with('well otrne'r•
repair m061.1121 remarks section or on the back of this Jorat. I.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the saute
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also'attach additional pages if necessary.
drilled:,_
SUBMI.1"I'AL INS'l'RUCTIONS
9.Total well depth below land surface: 725
Far multiple ti c/Is list all depths ifd irca/(example-3 rd 2nn'and 2 a!00') M.) 24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following: ,
10.Static water level below top of casing: 60 (ft.) Division of Water Resources Information Processin Unit If water level is above casing,use"+•• > g ,
1617 Mail Service Center,Raleigh,NC 27699-1617 •
6 I .
I I.Borehole diameter: (ill.) 241). For Infection Wells: In addition to sending the(brat to the address in 24a
12.Well construction method: above, also submit one copy of tliis roan within 30 days of completion of well
(i.e.auger,rotary,cable,direct-push,etc.) construction to the following: I
I
Division of Water Resources,iUrille•ground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
I
13a.Yield(gpm) 8 Method of test: AIR 24c. For Water Stnnly& Infection Wells: In addition to sending the form to
HTH the address(es) above, also submit:one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction io the county health department of the county
where constricted.
Fein OW-I North Carolina Department ofEnvironmentnl Quaality-Division of Water Resources Revised 2-22-2016
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