GW1--00587_Well Construction - GW1_20240118

WELL CONSTRUCTION Rit'CORD (GW 1) i I Print Form
I For Internal Use Only:•
1.Well Contractor Information:
RANDY OWNBEY
Well Contractor Name FROM
WATER ZONES i -
FROM TO DESCRIPTION
3214A 269 fly 270 ft.
NC Well Contractor Certification Number ft. ft.
AIR DRILLING INC 15.OUTER CASING(for mutts-citsbd wells)OR LINER(If op Ilcable)
FROM TO i
DIAMETER TIIICKNESS �MATERIAL
Company Name0 ft. 175 ft. 6 j in. PVC
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM fro DIAMETER THICKNESS MATERIAL
List all applicable ied/construrlion permits(i.e. U/C,County,Slate, Variance,etc.) ft.
ft. 1 in.
3.Well Use(check well use): ft. ft. i ill.
Water Supply Well: 17.SCREEN
Agricultural / momoM To DIAMI ript SLOTSLOTSIZE THICKNESS \IA•rEItM I,
[Municipal/Public ft. ft. III.
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single)
Industrial/Commercial ft. ft. in.
�Reeidenlial Water Supply(shared)
irrigation 18.GROUT
FROM • To MATERIAL EPIPLACEMENTJIE'rIIODR:\MOUNT
Non-Water Recovery
0 f' 20 lt' GROUT POURED
Monitoring Recovery
Injection Well: ft. ft.
Aquifer Recharge [Groundwater Remcdiation . ft. ft.
Aquifer Storage and 19.SAND/GRAVEL PACK(If applicable)
Salinity Barrier FROM TO MATERIAL EMPLACEMENT\IIiTRUU
Aquifer Test QStormwatcr Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 1=J 20.DRILLING LOG(attach additional sheets If necessary)
Geothermal(Heating/Cooling Return) `Other(explain under 1121 Remarks) FROM ro I)KSCRIP'I'ION(color,hardness,sot Wrack type.grate she,etc.)
0 ft' 65 ft• DIRT
4.Date Well(s)Completed: 10-17-23 Well ID!/ 65 ft. 285 ft. --
ROCK
5a.Well'Locntion: ft. ft.
DEWEY MESIMER ft. ft.
Facility/Owner Name Facility IDlt(if applicable) • ft. ft. , U a,.,�.i, V 4...,L
9022 ARCHER RD,DAVIDSON,N.C. 28036 ft. ft. • //,, c
Physical Address,City,and Zip ft. ft. 4 J1 i`i Q l07
CABARRUS 21.REMARKS ; 1 i rr;rc}j;); U¢,;i
i ftt.:,-
County Parcel identification No.(PIN) fSht`co3
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
35° 30.329 N 80° 43.809 zz.Ccrtifjcat'
W ' 10-17-23
6.Is(are)the well(s)0IPermanent or DI'I'emporm•y Signnh o Corti di aractor Date
By.signing this form,/hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [Yes or 0No with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
Olds is a repair,fill oat known,refl contraction h ftrmatim,and explain the nature(lithe copy of this record has been provided In the well Owner.
repair under 112/rentcaks section or on the back of this form.
23.Site diagram or additional well details:
S.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
construction details. You may also attach additional pages if necessary.
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9.Total well depth below land surface:
SUBMITTAL INSTRUCTIONS
285 •
For nnthiple,cells list all depths ifdi�ereot(example-3@200'200'and 2 a l00') (f t') 24a, For All Wells: Submit Ibis form within 30 days of completion of well
construction to the following:
10.Static water level below top of casing: 50
If water level is alum casing,use"+" (ft.) Division of Water Resources,Information Processing Unit,
6 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.)
24b. For Infection Wells: in addition to sending the form to the address in 24a
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,eta)' construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Conh of Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 20 Method of test:AIR 24c.For Witter Supply & Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 clays 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