GW1--00716_Well Construction - GW1_20240119

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WELL CONSTRUCTION RECORD (GW-1) I I Print Form
For Internal Use Only:
1.Well Contractor Information: i
RANDY OWNBEY
14.WATER ZONES I
Well Contractor Name FROM TO DESCIuI"rION
3214A ' 629 rt• 630 it I i
NC Well Contractor Certification Number ft. ft. I t
n
AIR DRILLING INC 15.OUTER CASING(for multi-cased,wells)OR LINER(Yap doable)
FROM TO DIAMETER THICKNESS MATERIAL
Company Name ft. 41 ft. 6 I I in. PVC —
2023-30327 16.INNER CASING OR TUBING(geothermal closed-loop)
Z.Well Construction Yennit#: FROM TO • DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits(i.e.Inc,County,State,Variance,etc.) rt. ft. I I in.
3.Well Use(check well use): IL ft. la.
Water Supply Well: • 17.SCREEN 1 ,
FROM TO DIAM ETU SLOT SIZE 'i•IIICKNESS S IA'I'ERIA I.
pAgricultural DMtmicipal/Public ft. ft. h.
'Geothermal(Heating/Cooling Supply) X[�Residential Water Supply(single) --
tt, ft. in.
Industrial/Commercial DResidenlial Water Supply(shared)
18.GROUT
Irrigation FROM TO MATERIAL ESil'LACEMENTrslETllOD&AMOUNT'
Non-Water Supply Well: 0 R, 20 rt• GROUT POURED
Monitoring DRecovety ft. R.
Injection Well:
Aquifer RechargeGroundwater Rentcdiation ft. ft.
Aquifer Storage and Recovcl ND/GRAVEL PACK(If applicable)
y DSalinity Barrier :119RiS:Ali
TOMATERIAL, ESIPI.ACEMEN'IMETnoAquifer Test []IStormwater DrainagefLft.
,Experimental'I'echnology ©Subsidence ControlI't. ft. I'Geothermal(Closed Loop) ©I'I'rticer 0RILLING LOG(attach additiontil sheets if necessary)Geothermal(Heating/Cooling Return) Other(explain under'#21 Remarks) 1'0 DESCRIPTION(color,hardness,soil/tact:lrlte irate size,etc.)
0 rt. 31 ft. DIRT,
4.Date Well(s)Completed: 10-11-2023 Well ID# 31 ft. 645 ft. ROCK
5a.Well Locution: ft. It.ell
DERRICK OSBORNE BUILDERS R. ft. 1 :V --'`;,~•
�,.�
•I-I,\ ".. r-
I' 'ri..s7 .. U,1 J_ �
Facility/Owner Name Facility 1011(if applicable) ft. ft. I
172 BUTCH BRANCH RD,UNION GROVE,N.C. 28689 ft. ft. I A i Ct1-24
Physical Address,City,and"Lip ft. ft. ,' s .- Prcv-•.z.z!nri ( ~
IREDELL
4844-11-1363 zLREMARKs � uteC.:;'�s:l�;
County Parcel identification No.(PIN) 1'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one let/long is sufficient) —'—
22.C. ,lion:
36° 20.347 N 80° 53.428 W
. 10-11-2023
G.Is(are)the well(s)0X(Permanent ot• 1•1'emporary Signature of Certified Well Contractor Date
ilp signing this Arm 1 herehv ccrtJt'that I(c well(,)was(were)constructed in accordance.
7.is this tI repair to an'existing well: 0Yes or ONo with ISA NCAC 02C.0/00 or 15,1 NCAC 02C.0200 Ire Corts1raction Standards and that a
If this is a repair,Jill out known tied!construction"affirmation and c:q,lain the nature of the copy°P'dhis record has hee,pr•ot'ider!a,the•n`•e!l nn•ner•
repair under 1121 remarks section a•on the back oJ'this Jbrm. 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 constriction details. You may also attach additional pages if necessary.
drilled: II
SUBMITI•Al,INSTRUCTIONS ,
9.Total well depth below land surface: 645 i
!•br,nuhlple wells list all depthsifd#Jerent(example-3 rJi200'and 2 a/00') (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
10.Static water level below top of casing: S0 (ft.) Division of Water Resources;Information Processing Unit,
ff u'arcr level ix abate casing,use"-I-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b. For infection Wells: in addition to sending the form to the address in 24a '
above, also submit one copy of this form;within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,sully,cable,direct push,etc.)
Division of Water Resources;Underground Injection Control Program,
FOR WA i'L R SUPPLY WELLS ONLY: 1636 Mail Service Center;Raleigh,NC 27699-I636
I3a.Yield(gpm) 5 Method of test:AIR 24c.For Water Sunni),& Injection Welk: In addition to sending the form to
HTH the address(es) above, also submit one'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 constntcicd.
Form OW-I • North Carolina Department of Environmental Quality-Division of Water ResourcesI Revised 2-22-7.016
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