GW1--00656_Well Construction - GW1_20240119

WELL CONSTRUCTION RECORD GW_1 Print Form
) For Internal Use Only:
1.Well Contractor Information: I
RANDY OWNBEY
l
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3214A 549 ft. 550 ft.
NC Well Contractor Certification Number ft ft.
AIR DRILLING INC 15.OUTER CASING(for multi-cased wells)OR LINER(Bap licable)
FROM i TO I DIAMIETERI THICKNESS MATERIAL
Company Name 0 ft. 85 ft. 6 ; !In. + GALV
313802 16.INNER CASING OR TUBING(geothermal closed-loan)2.Well Construction Permit II: FROM TO DIAMETER THICKNESS MATERIAI.List nil applicable well couytrttr•tion permits(i.e.111C,County,Slam,Variance,is nce,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
'Agricultural FROM TO DlnelblEtt SLOT SIZE THICKNESS atATt:ts t,Municipal/Public ft. ft. iw.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
ft. ft. Ina
Industrial/Commercial Residential Winer Supply(shared)
18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD.3,AMOUNT Non-Water Supply Well: 0 ft' 20 a. GROUT
Monitoring POURED
0Recovery ft. ft.
Injection Well:
Aquifer Recharge DGroundwatcr Rcmcdiation ft• ft.
Aquifer Storage and Recovery19,SAND/GRAVEL PACK(if applicable)
�ISalinity Barrier FROM TO MATERIAI. EMPLACEMENT\IETtlot)
Aquifer Test �Stonnwatcr Drainage
DSubsidence Control
ft, ft.
Experimental Technology
Geoth ft. ft.
20.DRILLING LOG(attach additional sheets If necessary)
Geolltcnnal(Closed Loop) D•fracer
Geothermal(1{oatiug/Cooling Return) [�IOlher(explain under 1P21 Remarks) FROM To DESCRIPTION(calor,tinniness,soil/nick type,grain size,etc.)
0 " 75 ft. DIRT
09-13-2023 !
4.Date Well(s)Completed: 09-13-2023
Well ID# 75 ff. 565 II. ROCK
5a.Well Location: ft. ft.
JEFF ONSRUD ft. ft.
Facility/Owner Name Facility llll!(if applicable) ft. ft. ^r
t'''F �,..a,..,-,
259 RIVERBEND DR,MOORESVILLE,N.C. 28117 ft. ft. '.'�b., �„__ . �,' i;
Physical Address,City,and Zip ft. ft. Jh�, 9 2024
IREDELL 4639002660 21.REMARKS
County Parcel identification No.(PIN) iili'.':,'a :'oil Pr^;:�^r;r a
9 Ur
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one Iatllong is sufficient) 22.Certit5ca ' n:
35 37.968 N 800 55.037
`� .�y 09-13-23
6.Is(are)the well(s) X Permanent orQI'I'emparm y Sign, of lc ontfi / - Date
Ily signing this form,1 hereby cerlfy that the well(s)was(here)contracted in accordance
7.Is this a repair to an existing well: 0Yes or ONo with ISA NCAC 02C..0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
Iflhis is a repair,Jill out known well construction inlbrnmtion and explain the nature al the copy al this record has been pint ided to da•hrell owner.
repair under 112/remarks section or on the back of this
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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9.Total well depth below land surface:
565 SUBMIT"I'AI.INSTRUCTIONS '
For multiple tiple wells list all depths Ifd Jr rem!(crumple-3 a 200'uurl2 rt ron') (ft-) 24a. For All Wells: Submit this ferns!within 30 days of completion of well
30 construction to the following: I '
10.Static water level below top of casing:
?Twofer level is above erasing,use"+'• (ft.
) Division of Water Resources,information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b. For Injection Wells: in addition to sending the form to the address in 24a
12.Well consiruetion method: above, also submit one copy of this form within 30 clays of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,;Raleigh,NC 27699-1636
m 8 AIR
13a.Yield
(gP ) Method of test: 24e. Fo•Water Shinty& Injection Wells: In addition to sending the form to
HTH the address(es) above, also submit one 1copy of this form within 30 clays of
13b.Disinfection type: 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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