GW1--00585_Well Construction - GW1_20240118

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WELL CONSTRUCTION RECORD (GW-1) For internal Use Only:
1.Well Contractor Information:
RANDY OWNBEY . 14,WATER ZONES i
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Well Contractor Name FROM TO DESCRIPTION
3214A 389 ft' 390 ft. T
ft. rt. ----
NC Well Contractor Ccni9cation Number
15.OUTER CASING(for multi-cased wells)OR LINER(if op Ilcable)
AIR DRILLING INC FROM To DIAMETER : THICKNESS MATERIAL
--
0 It. 140 ft. 6 6 1 in. PVC
Company Name
1045 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAI.
List all applicable well cansn•actian permits(i.e.(/IC,County,Slate, Variance,etc.) ft. ft. , in. ___
3.Well Use(check well use): ft. ft. in.
WNater Supply Well: 17.SCREEN
FROM TO DIAMETER , SLOT SIZE THICKNESS \IA'I'ERIA I.
Agricultural Municipal/Public ft. et. In. —'
Geothermal(Heating/Cooling Supply) [Residential Water Supply(single) — ft. ft. in. .-____
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL E\1P1.:\CEMEN'i•METHOD K:\\•COUNT
Non-Water Supply Well:
Monitoring
0 ft' 20 ft. GROUT POURED — —
Recovery ft. ft. -- --
Injection Well:
ft. ft.
Aquifer Recharge JGroundwater Remcdiation
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19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT MItTIIOD
Aquifer TestExper �Slormwater Drainage ft. ft.
Geothermal
l nology (Subsidence Control I'I. ft.
Geothermal(Closed Loop) ©I'I'racet 20.DRILLING LOG(attach additional sheets if necessary)
•Geothermal(tleatin /Conlin Return) FROM ro DESCRIPTION(enter,hardness,salt/reel:tape,grain size.etc.)
g g DOther(explain under 1121 Remarks) 0 ft. 130 ft. _ •DIRT __
4.Date Well(s)Completed: 11-29-23 Well IDII 130 ft• _405_it' ROOK
Sa.Well Location: ft. — rt.
4 G BUILD ft. ft.
'Facility/Owner Name Facility ID!!(if applicable) ft. ft. 4. .' -s't L.•..4 a Lam..L—
5519 LIBERTY RD,GRANITE FALLS,N.C. 28630 ft. ft. JAN I %Q?4•
Physical Address,City,and Zip ft. ft.
21.REMARKS i ti CALDWELL 2755501499 nwr„�s_w(C-O r'. ..lx:R't4a.y G:•JL
R�
Gov '/6
County Parcel Iciest)Ficntion No.(PIN) 1 ___—___—._-___-____
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: .._.____-
(ifwell field,one Ina/long is sufficient) 22.Certif' , n:
35° 47.155 N 81° 30.712 W
11-29-23
6.Is(are)the well(s)IX Permanent or JTemporarh Sign,litre ol'Cc red We Contractor Date
Ov signing this fa•s:,1 hereby certify that the well(.) was(true)constructed in accorrlani:c
7.Is this a repair to an existing well: Dyes or f No with 15A NCAC 02C.0100 or 15A NC.,1C 02C.0200 Well Construction Standards and shut a
If this is a repair,fill out known well conslraclinn it formation and&&plain I/ic naltnr gfthc' copy"phis record has bee"provided to the well awaer%
repair under 1121 retmarkr section or on the back of this fora.
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 site details or well
construdtion,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 surface: 405 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi(jetrnl(example-3@200'and 2(),/00') construction to the following:
I
10.Static water level below top of casing: 40 (11.)
Division of Water Resources,information Processing Unit,
lftrarer level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 6 in.
( ) 241). For Infection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this(form within 30 (lays 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) 30 Method of test: AIR 24e.For Water Supply & Inicction 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 GW-I North Carolina Department of Environmental Quality-Division of Water Resources• Revised 2-22-2(116