GW1--00571_Well Construction - GW1_20240118

WELL CONSTRUCTION RECORD (GW-1) Print Form -
For I`irterlial Use Only: i� �—'"—
1.Well Contractor Information:
RANDY OWNBEY • 14:WATER'.zoNES '`-
Well Contractor Namc FROM' "1'O DESCRIPTION
3214A 889 et. $00 ft.• '' I .
ft. ft. ,. , . I , -
NC Well Contractor Certification Number
IS.OUTER CASING(for:multi-cased•wells)OR LINER(if op limbic)'
AIR DRILLING INC _FROM '` TO! ', _ 'rER!DIAME ' ,THICKNESS MATERIAI.
ft. 48 rt. : 0 �t�+, PVC
Company Name 0
16.INNER CASING OR TUBING(gcotlierniul closed-look 2.Well Construction Permit#: . -FROM TO ' 'DIAMETER' ' 'THICKNESS MATERIAL '
List all applicable well construction permits(i.e. U/C,Calmly,State,Variirnce,eh•) ' ft. ' • ft. ;in.
3.Well Use(check well use): ft. ft. ;in, ' '
Water Supply Well: ,17,SCREEN
FROM ` 'TO .. DIAMETER .SLOT SI'ZE' TincicNESS' PIATtRIAI,Agricultural OMunicipal/Public ft. 'ft. ' in, , ' '
Geothermal(Heating/Cooling Supply) Ellkesidential Water Supply(single)
I. ft. lii,
Industrial/Commercial OResidential Water Supply(shared)
18.GROUT
, Irrigation 'FROM 'i TO' MATERIAL EMPLACEMENT METHOD SA\IOUNT
Nun-Water Supply Well': 0 ft. 20 ft. GROUT POURED
Monitoring DRecovery ft. ft. T'
Injection'Well:
• ft. ,ft. ,A Aquifer RechargeDGroundwatc Remcdiation -
Aquifer Storage and Recovery OSalinity Barrier 19:SAND/GRAVEL PACK(If applicable) '
L.F Y FROM TO MATERIAL. EMPLACEMENT ME HoD
Aquifer'rest DStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft.' ft. t
Geothermal(Closed Loop) °Tracer , 20.DRILLING LOG(attach additional sheets If necessary)
Geothermal(Heating/Cooling Return) Other(explain under Remarks) FROM • TO nEs'cRn"i'ior(color,hardness,sod/rock type,grain size,etc.)
tt. 38 fi, 'DIRT
4.1)atc Well(s)Completed: 9-7-23 Well lmit 38 ft.' 905 .ft. ROCK .
5a.Well Location: ft. ft.
JIM MERRITT - ft. • ft.
Facility/Owner Name Facility IDS(if applicable) ft. ft. • -:;,r C. ,`q'{_� .
200 MERRITT WAY,LEXINGTON,N.C. 27295 , 'ft. 1 ft. "' .'_ .
Physical Address,City,and Zip ft. ft. Jltil� 2024
DAVIDSON 21.REMARKS ' ' •
County Parcel Identification No,(PIN) tra.z.gi,kit fret:.- :•, c�.r.,g vr„i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certifi n:
35° 52.523 N 80° 22.571 W
9-7-23
6.Is(are)the well(s)JPermanent or OTemporary Sign, ire of Cc cd We ontractor " Date
By signing this form,1 hereby certify'Mal the well(s)'vas(were)constructed hi accordance
7.Is this'a repair to an existing well: Dyes or ONo with 15A NCAC 02C.0100 or/5A NCAC 02C.0200 IVell Construction Standards and that a
If this is a repair,fill out known well consn•uction h fn•nwtion and explain the nature of the copy of this record has been provided to the weli owner.
repair under 112/remarks section or on the back o/`this JOrnt.
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/UPT or Closed-Loop Geothermal Wells having the same
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
SUBMITTAL INSTRUCTIONS
9.Total'well'depth below land'sm face: 905 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For umhiple wells list all depths(/'different(example-3@200'and 2 a 100') construction to the following:
10.Static water level below top of casing: 50 (ft.
) Division of Water Resources,information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6. (in.) 24b. For Infection Wells: in addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 15 Method of test: AIR . 24c. For Water Sunnis, & Infection Wells: In addition to sending the form to
the address(es) above, also submit one 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, •
Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016 ,