GW1--00657_Well Construction - GW1_20240119

l
_ WELD CONSTRUCTION RECORD GW-1 Print Form
Por Internal Use Only: .
1.Well Contractor information:
RANDY OWNBEY
Well Contractor Name 14.WATER ZONES I
FROM '1'0 DE.SCRIP'1'ION
3214A _ 229 rt. 230 et.
NC Well Contractor Certification Number ft ft.
AIR DRILLING INC 15.OUTER CASING(for multi-coxed Wells)OR LINER(if ap Ilcable)
FROM ft TO l DIAMETER! THICKNESS I MATERIAL
CinnpunyName 0 . I 40 ft. 16 I .in. PVC
16.INNER CASING OR TUBING(geothermal closed-loop)
2,Well Construction Permit#: 2023-34228
FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County,State,!Variance,etc.) ft, ft. .in.
3.Well Use(check well use): ft. ft. 'in.
Water Supply Well: 17:SCREEN
•
Agricultural FROM TO DIASIE'I•ER, SLOT SIZE THICKNESS MATERIALMunicipal/Public ft. ft. in.l '
Geothermal(Heating/Cooling Supply) t�IResidenlial Water Su I 1
t=F Supply(single) ft, rt. in.I,
IndustriaUConnmercial DResidential Water Supply(shared)
Irrigation 18,GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 rt. GROUT POURED
Monitoring DRecovery
Injection Well; ft. ft.
Aquifer Recharge OGroundwater Rentcdiation ft. ft.
Aquifer Storage and RecoverySalinity Barrier 19,SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL , EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology OSubsidenee Control ft. ft.
Geothermal(Closed Loop) ❑ITracer 20,DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) [Other(explain under#21 Remarks) FROM ro DESCRIPTION(con„,bareness,soil/rack type,grain ales,etc.)
09-14-2023 0 ft' 58 ft. DIRT
4.Date Well(s)Completed: Well ID# 58 ft, 245 ft,
ROCK
Sa.Well Location: ft. fl,
I
MATTHEW MCCONNELL ft. ft.
Facility/Owner Name Facility ID!!(if applicable) ft. ft. ;_ 4.,P I::--,
�r-V I. 1
1535 MT ULLA HWY, MOORESVILLE,N.C, 28115 ft. ft,
'IA Pi 1 9 2024
Physical Address,City,and Zip ft. ft.
IREDELL 4679323876 21.REMARKS In v' iT:V.IVI Pr:-M 3 UIr.
Parcel ldentificationNo.(PIN) LIo'CIOCz
County
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56.Latitude anti longitude in degrees/minutes/seconds or decimal degrees:
' (if well field,one lat/long is sufficient)
22.Certific n:
35° 38.415 N 80°46.361
W I 9-14-23
©ITemporary Signature ofCertifiied Well Contractor Date
6.Is(are)the well(s)OPermanent ,or
By signing this fats, I hereby cert fv!hal the well(s) was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or DNo with Mt NCAC 02C.0/00 or 1SA NCAC 02C.0200 II'el!Comm:ction Standards and that a
lfthis•is a repair.fill out known well consa'uclion LJhrmation and explain the nature Vibe o copy ofthis record has been provided to the'urll owner.
repair under 021 remarks section or on the back()Phis form.
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the sane You may use the back of this page toiprovide additional well site details or well
construction details. You may also attach additional pages if necessary.
construction,only 1 CW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 245 -
For multiple wells list all depths Ild�t'rent(example-3 a 200'and 2 a)I00') (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
10.Static water level belowtop of casing; 40 (ft.)
((water level is•above casing,use"+ Division of Water Resources,Information Processing Unit,
6 1617 Mail Service Center,Raleigh,NC 27699-1617
1 I.Borehole diameter: (in.)
24b. For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: above, also submit one copy of this felon within 30 days of completion of well
(i.e.,auger,rotary,cable,direct push,etc.) conslructionsto the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,'Raleigh,NC 27699-1636
13a.Yield(gent) 20
Method of test: AIR 24c. For Water Sunni),& Infection Wells: In addition to sending the form to
13b.Disinfection t= HTH the address(es) above, also submit ode copy of this form within 30 days or
JPc: Amount: completion of well construction to'the'county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016