GW1--00713_Well Construction - GW1_20240119

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:' . I �—
1.Well Contractor Information:
RANDY OWNBEY -14;WATER ZONES •.l• I .. ' . _
Well Contractor Name FROM ' TO.. DESCRIPTION
3214A 489 ft. 490 ft.
ft. ft.
NC Well Contactor Certification Number
.15:OUTER'CASING(for multi-cased r'vells)OR;LINER gapQlicahle) -
AIR DRILLING INC FROM TO DIAMETER 1 TIIICKNESS I MATERIAL
0 ft. 120 ft. 0 I . PVC
Company Name
314499 16.INNER CASING OR TUBING'(geothermal closeil-loop) •• . .
2.Well Construction Permit#: FROM ' TO DIAMETER i THICKNESS MATERIAL
List all applicable well construction permits(i.e.U/C,County,State,Variance,etc.) ft. ft. 1 in.
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3.Well Use(check well use): ft. ft. l, Ill. —
I Water Supply Well: l7.SCREEN
FROM TO DIAa1R'IKII SLOT SIZE TIIICKNESS MIATERLU.
Agricultural OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) IDResidential Water Supply(single) ft. ft. in.
Industrial/Comnercial Residential Water Supply(shared) 18,GROUT
Inigation
Non-Water Supply Well:
- FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
0 ft• 20 ft' GRUUI' POURED
t
Monitoring Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Rcmcdiation '
1.
19.SAND/GRAVEL:PAC►C(ifapplicable).'
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test �Stormwater Drainage R. ft. I'
Experimental Technology 9Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20,-DRILLING LOG(attach additibnaLshcets if necessary) .'
FROM '1'O
0 ft. 110 ft• DESCIt1P'I'ION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Fleating/Cooling Return) QlOther(explain under 421 Remarks)
DIRT
4.Date Well(s)Completed: 06-15-23 Well IDl/ 110 ft. 505 ft. ROCK I ,
Sa.Well Location: ft. ft. ". >, ——
DERIK BALTI-CH ft. rt. — —1—7— y '---- -�`— "tt^»�'+-.--
Facility/Owner Name Facility IOU(if applicable) It' it• - ;' JA N 1 9 2024
165 Ross Rd ,MOORESVILLE,N.C. 28117 ft. ft.
, Ins- :r..t:`,:,,
Physical Address,City,and Zip ft. ft. DV..•,�'` K y; (.Fei
IREDELL 4638019306 .21.REMARKS " . - . ' .. .
County Parcel Identification No.(PIN) ________
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: _
(if well field,one tat/long is sufficient) 22.Certifi - on: '
35° 36.414 N �,80° 54.879 j,
i 06-15-23
6.Is(are)the well(s) X, Permanent or Temporary Signature of Certified Well Contractor ' Date
By signing this farm,I hereby certify that the well(s) was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or f No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair.Jill out known well construction information and explain the nature of the copy of this record ins been provided to the well owner.
repair under 1121 remarks section or on the back of this form.
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23.Site diagram or additional well details:
8.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,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: _-, ---- SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: 505 (ft.) 24a. For-All Wells: Submit this form within 30.days of completion of well '
• Par multiple wells list all depths i(/'diykrent(e.ranple-3@200'and).a/00') construction to the following: 1
10.Static water level below top of casing: 50 (ft.) Division of Water Resources,(Infortnation Processing Unit,
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If tinter level is above casing,use'•+"_ 1617 Mail Service Cenrerl,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) '
24b.For Injection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this forin within 30 days of completion of well
12.Well construction method: construction to the following: I
(i.e.auger,rotary,cable,direct push,etc.) Division of Water Resources,Underground Injection Control Program,
FOR-WATER SUPPLY WELLS ONLY: 1636 Mail Service Center',Raleigh,NC 27699-1636
13a.Yield(gpm) 15 t Method of test: AIR 24c. For Water Supply&lnlectionkWells: In addition to sending the form to
HTH the address(es) above, also submit tine copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016