GW1--00570_Well Construction - GW1_20240118

WILL CONSTRUCTION RECORD (G W-1 Print Form
) For Internal Use Only: _.___
I,Well Contractor Information:
RANDY OWNBEY ,
14,WATER ZONES
Well Contractor Name FROM To DI:SCIi1P79oN
3214A 439 r`' 440 '`
NC Well Contractor Certification Number ft rt'
AIR DRILLING INC 15.OUTER CASING(for multi-cased wells)OR LINER(flap [Kahle)
FROM TO• ' DIAMETER THICKNESS MATERIAL
0 ft' l 144 ft. 8 ! In. GALV
Company Name —
16,INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL.List all applicable well consrrtrt•finn permits(Lc: WC,County,.Sale, Variance,etc,) fl. ft. I in. __. _
3.Well Use(check well use): ft, ft. ; in.
Water Supply Well• 17.SCREEN
—}Agricultural , FROM TO DIAMETER SLOT SIZE THICKNESS n lATER IA I.ti + OMunicipal/I ublie et. ft. In.'
'Geothermal(Heating/Cooling Supply) DResidential Water Supply(single)
ft. ft. in,
IndustriaVConmlercial DResidential Water Supply(shared)
18,GROUT •
Irrigation FROM To MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft, GROUT POURED
Monitoring DRecovery rt. ft.
Injection Well:
Aquifer Recharge DGroun(iwatcr Rcmcdiation ft. ft.
DAquifer5loage and RccoVel 19,SAND/GRAVEL PACK(if npplfcable)
y DI Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
QAquifer Test OStormwatcr Drainage ft. rt. I
0Experimental Technology DSubsidence Control IL I't, I.
DGeothermal(Closed Loop) OTracer 20,DRILLING LOG(attach additional sheets If necessary)
fiGcothermal(Heating/Cooling Return) OlOther(explain under#21 Remarks) r•ROnt ro DESCRIPTION(color,hardness,soil/ruck hue,grain sloe.etc.)
0 etc.). 134 IL DIRT!
4.Dale Well(s)Completed: 10-23-23 Well IDII 134 ft• 455 ft'
ROCK
5a.Well Location: ft. it. —� —' —
I
EGGER WOOD PRODUCTS ft. ft. —
Facility/Owner-Name Facility Illll(it'applicable) IL ft. r E. ""�'A
300 EGGER PKWY,LINWOOD,N.C.27299 It. n, — ,_ '), ' „. air ----
Physical Address,Ciiy,'•as'd;Zir ft. ft. J�� 8 � t�
DAVIDSON .. ..... 2.:: 21.REMARKS
County Parcel Identification No.(PIN) I11���;� ;�� f7f^'� y'� ~�U'
� n nrr
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Orwell field,one lat/long is sufficient) 22.Cer' ,lion:
350 44.283 N 800 20.938
W 10-23-23
6.Is(are)the well(s)IPertnnnent orD'I'empm•ary Signature of Certified Well Contractor i Date
Bysigning this Arm, l hereby ccrti/h thaC the yell(,) was(were)constructed in accortla,eo
7.Is this a repair to an existing well: DYes or ONo with/SA NCAC 02C.0100 or ISA NCAC'0 C.0200 Well Construction Standards and that a
Obis is a repair,fill out known well construction h fnoration and c/ilaiit the nature(tithe caps of this record lute been provided t,thh well"'Her.
repair under 1121 remarks section or on the back of this•/ornt.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction details. You may also attach additional pages if necessary,
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells
drilled:
SUBMI'I'•I'AL INSTRUCTIONS ' '
9.Total well depth below land surface: 455
Frnr,mrbiplene/lsnrta//de),rhri/d�e,•enf(t.,ontp/e-3@200 and2�ronq MO24a• 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: 50 (ft.) , i •
If latter level is above casing,use"•t•' ( ) Division of Water Resources;information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11,Borehole diameter: 8 (in.)) 24b. For Injection Wells: In additionto sending the torn, to the address in 2,18
12.Well construction method: above, also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following: I
FOR WATER SUPPLY WELLS ONLY; Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Ccn'tcr,Raleigh,NC 27699-1636
13a.Yield(gpm) 250 Method of test: AIR 24c. For Water Supply& Infection Wells: In addition to sending the form to
the address(es) above, also submit brie copy of this form within 30 days of
13b.Disinfection type: HTH Amount: completion of well construction to the county health department of the county
where constructed.
Forn,cw-I !
North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-20I6