GW1--00645_Well Construction - GW1_20240119

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
RANDY OWNBEY ,_ 94,WATER ZONES I
Well Contractor Name MGM TO' "" DESCRIPTION
3214A 349 rt. .350 rt.
ft. ft.
NC Well Contractor Certification Number
AIR DRILLING INC '15r01. ERCASiNGlorintiltl=casidlwells)ORLINER(Ifap[licabte
y FROG Nth_ —TO DIAMETER ! 'THICKNESS I MATERIAL.
Company Name o ft. 'g ft. 8 !: In.
• PVC
390515 •
16.INNER.CASING OR TUBING(geothermal closed-loop
2,Well Construction Permit#: FROM ' TO. DIAMETER' THICKNESS MATERIAL
List all applicable well construction pm-soils(i.e.U/C,County,State,Variance,etc.) . ft. ? ft. i' tn.
IWell Use(check well use): ft. ft. In.
Water Supply Well: 17.SCREEN
Agricultural FROM ''1.O DIAMETER SLOT SIZE Ti IICI<N MS AIAI.ER IA I.
g Municipal/Public ft, ft. In,
Geothermal(Heating/Cooling Supply) EllResidential Water Supply(single)
ft. ft. In. '
Industrial/Commercial OResidential Water Supply(shared)
ISrGROUT ,: - •'
irrigation FROM TO MATERIAL .EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ' ft. 20 ft, GROUT POURED
Monitoring ORecovery ft. ft.
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Injection Well:
Aquifer Recharge ft. ft.
.,
ElGroundwater Rcmcdiation
Aquifer Storage and Recovery r�^'�Salinil Barrier "19.'SAND/GRAVEL"PACK(if applicable)'
y FROM TO'` • MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology DISubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer -20,'DRILLING LOG(attach additional sheets If necessary).. '
Geothermal(Heating/Cooling Return) Other(e plain under d/21 Remarks) FROM '1'0 DESCRIPTION(color,hardness,solt/roeh type,groin size,etc.)
p• ft. Bg ft. DIRT I'
4.Date Well(s)Completed: 08-15-2023 Well ID# 69 ft. 385 ft.
ROCK I +, a
5a.Well Location: ft. ft. �,—'f /; ;, y a
BARRY BOECKENSTEDT ft. ft. J4N
n24
Facility/Owner Name ft.Facility IDN(if applicable) ft.
11941 NC 801, MT ULLA,N.C. 28125 ft. ft. nf�;�•-�=�=') ter-::;sq.
Physical Address,City,and Zip ft. ft.
ROWAN 558012 r 21.REMARKS' . ' 1'
County Parcel identification No,(PIN)
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long ii sufficient) 22.Certif:tion:
35°40.231 N 80°41.423 W I
08-15-2023
6.Is(are)the well(s)lPermanent or Temporary. Signature of Certified Well Contractor i; ' Date
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By signing this form,/hereby ccrtlfy that uhe we/i(s) was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or ONo will//5A NC/IC 02C.0/00 or/SA NCAC 02C.0200 IVell Construction Standards and than a
If this is a repair,fill out known well construction irfrrntation and explain the nature of the copy of this record has been provided to lhe;well owner.
repair under#2!remarks section or on the back of this form. 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 same
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details, You may also attach additional pages if necessary.
drilled:
SUBMITTAL INSTRUCTIONS it
9.Total well depth below land surface: 365 (ft.) 24a. For All Wells: Submit this form within 30 days-of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@!00') construction to the following:
10.Static water level below top of casing: 04 (ft.) Division of Water Resources;Information Processing Unit,
If ivater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For inflection 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,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,,Raleigh,NC 27699-1636
13a.Yield(gpm) 7 Method of test: AIR 24c.For Water Supply 8:IniectioniWells: In addition to sending the form to
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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. I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016
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