GW1--00710_Well Construction - GW1_20240119

WELL CONS'IRUC'I'ION RECORD (GW-1)
]tor internal Use Only:
I.Well Contractor Information: 1
RANDY OWNBEY 1 , I
Well Contractor Name`• 14,WATER ZONES I I
FROM '1'o DESCRIPTION
_---1 i
I
3214Aft
489 • 490 f( I I
"-- —_._._.____..
NC Well Contractor Certification Number ft. ft.
IS.OUTER CASING(for multi-eased wells)OR LINER(if an tlicablo)
AIR DRILLING I N C !?Ito i 'r0 uldkd•r_r:R1 THICKNESS _ �I:\•rrail:\I.
Company Name 0 fL 63 n' 6 I tin.
n PVC _.__...__..
2,Well Consh'nctioit Permit/1: 2022-2540 16.INNER CASING OR TUBING(geothermal closed-loop) -—I
FRO\I TO _DIAMETER I T111(.'KNI:SS \TA:l'1111 0.
List all applicable well construction permits(i.e.(1/C,County.State, Variance,etc.) ft. fl•_ a,
3.Well Use(check well use): ft. ft. in
Water Supply Well:. 17.SCREEN ( I -
['Agricultural mom _To DIANtt rl':R 1. st,or sm.: •THICKNES6 NATERIA1. __
DMunicipal/1 ublie B. It, in.�,
Cloeothernial(Healing/Conlin);Supply) L•1Rcsidential Water Supply(single) -__
ft. ft. In,I-11ndustrial/Commercial [Residential Water Supply(shared)
fllrri)!:,tiotl 1S,GROUT i. ----
['Wells> 100,000 GPD FROM To Ai,t'r'tatr,\L EMPLACEMENT ali(Bent&AMOUNT
Non-Water Supply Well; 0 fl. 20 ft• GROUT POURED
i-I\-lunilurinhg ❑Recovery -------fL----- I•I-------'---•-------_-____.--------._...
Injection 11 ell: I -
I lAquiIi:r Recharge LIOroundwater Remediation n• ILI.
LiAquil'er Storage and Recover 19.SAND/GRAVEL PACK(If applicable)
Y USalinity Bonier FROM TO Si,\TERI Si. EMPLACEMENT LACEMENT\IM 110D DAquilbr'I'est DStormwatcr Drainage ft. ft. j
❑13xperimanlal Technology DSuhsidcncc Control ft, ft. it `- ""-.------"--._- -
Geotherrnal(Closed Loo 1'
I:"I
P) .CT aim- 20,DRILLING LOG(attach additional.sheets if necessary)
LiGeothermal(I!eating/Cooling Return) DOther(explain under 11.21 Remarks) r+goal _f0 DESCRIPTION(color,lateness,soil/rock type grata sirs,eic.l•_._
0 ft' 53 rt. DIRT
.1.Date Well(s)Completed: 05-03-2023 —_-._---
P Well um 53 rl• 505 rl• ROCK '_-_
Sa.Well Location: + ft. ft. i. -------------- --._.___
LAKEMIST HOMES — rt. —"—i't---- j-- —
Faeility I ecility ID/1(il'applit.ible) ft. ft. ,4,,
128 ADDISON EMORY LANE,MOORESVILLE,N.C, 28117 ft. ft. .
( \
Physical Address.City,and Lip fL frt. .
IREDELL • 4654784503 C(/[
21,REMARKS I11it'i(i-ate^pt.--.
Parcel identification No,(PIN) i'-- _ �•C1 01.
fib.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Is'well field.one ha/luop'is sufficient) ---- --------- -_— ---------
22,C;ertili ' n:
35°' 31 .126 80° 49.429 w _
1: ' _. 5/3/2023
o.Is(are)the well(s):iGIPermanent or IITemporary Signature nl'Curti ad Well Contractor I' Date
1, . .
By signing I:h./hi m,I hereby cer(i(i'rhar thej irell(s)was(mere)constructed in accordance with
7,Is this a repair to an existing well: Dyes or IJNo MI NC:IC 02C.0/00 or/Sd iVCWC 02.C.(1200 1Vel!Con.sn'iwiion Sramlarr/.s and(ba,a cope i/'(hds is a repair.fill oat known wen construction in/ormarion and captain the nature o/'the (Ohl',-eeord hex hem/u-orided to the well owner•
repair under(I.?!remarks section or on the back(Olds
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having die same You may use the back ol'this page tri provide additional well construction MR)
construction,only I GW-I is needed. Indicate TOTAL,NUMBER ol'wclls (add'See Over'in Remarks Box).You May also attach additional pages necessar
drilled:
— - --- — -_
24.SUBMITTAL INSTRUCTIONS l'
9.'I'otal well depth below land surface:.505 (ft,)
Far nn,hip/e wells liar all depths i/'dil/i•ren,(example-3 a)J.00'and 2(F 100') Submit this CW-1 within 30 days of well completion per the following;
10. water level below topof casing: 50 24a, For All Wells; Original form to Division of Water Itrsourcc, (DWR),
4 (fL) Information Processing Unit, 1617 MSC,'Raleigh,NC 27699-1617
IlB.Static level is above eosin, use"4."
24b, For Injection Wells: Copy to DWR, Underground Injection Control(IUC)
11.Borehole diameter: 6 (in,)
' Program, 1636 MSC,Raleigh,NC 27699-.1636 I
12.Well construction inethod: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
li.e.super,rotary,cable,direct push,etc.) county environmental health department di the county where installed
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells producing over 1�00,0(11)GPI): Copy to DWR,C'CPCUA
13a.Yield( Pm) 12 Method of lest: AIR Permit Program, 1611 MSC,Raleigh,NC 27699-I61 1
13b.Disinfection type: HTH Amanill:
fora OW-1 North Carolina Department ofEnvironmental Quality-Division or Water Resources
Revised 6-to-MIS
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