GW1--00717_Well Construction - GW1_20240119

WELL CONSTRUCTION RECORD GW-1 I I Prfnt Form
For Internal Use Only: '
1.Well Contractr Information:
I
RANDY OWNBEY
14,WATER ZONES
Well Contractor Name FROM •1'O DESCRIPTION
3214A . 549 f(' 550 I•t' - 1 1
NC Well Contractor Certification Number ft ft.
AIR DRILLING INC IS.OUTER CASING(for multl-caiedlwells)OR LINER(trap dicabie)
FROM TO DIAMETER THICKNESS MATERIAL _
Company Name 0 ft, 60 ft, 1 6 i ' (n, ' IPVC
OS WP-2022-9136 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: _PROM To DIAMETER THICKNESS MATERIAL__
List all applicable well construction permits(i.e. (/IC,County.State• Variance,etc.) fl, ft. in. —
3.Well Use(check well use): • ft. ft. in.
Water Supply Well: 17.SCREEN
Agricultural PROM 'I'O DIAMIrrRR SLOT SIZE THICKNESS MA'rER IA I_
YYY— OMunicipal/1 ublie ft. ft. in.Geothermal Supply) XfResidential Water Supply(single)
Industrial/Commercial ft• ft. "'•
Residential Water Supply(shared)
Irrigation
Non-Water Supply Well:
18.GROUT,
FROM TO MATERIALE\IPL,\CEM EMPLACEMENT METHOD R,\d10UNT
0 ft• 20 ft, GROUT
Monitoring
injection Well:
Recovery POURED
rt. ft.
Aquifer Recharge Groundwater Remcdiation rt. f.
•
Aquifer Storageand Recovery Salinity Barrier19.SAND/GRAVEL PACK(if appticiible)
FROM TO MATERIALEMi't.ACEMt:NT METHOD
Aquifer Test OSlorntwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. rt. I
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) i�IOther(explain under#21 Remarks) FROM TO DESCRIPTION(enter,IrwUness,.r'oll/rode type,grain size,etc.) _
10 16 2023 0 ft 50 ft' DIRT,
4.Date Well(s)Completed: Well ID# 50 il, 565 ft, ROCK
5a.Weil Location: rt. ft. —
PEACHTREE RESIDENTIAL ft. ft. 1,7 a #—
Facility/Owner Name Facility IDtt(if applicable) rt. ft. .T v,"y "y ' 1
140 DABBLING DUCK NOORESVILLE,N.C. ft. -- rt.
JAN 1 9 2024
Physical Address,City,and Zip ft. ft. ' ,
IREDELL 4636674037 2L REMARKS c0:r1'....
County Parcel identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Orwell field,one lat/long is sufficient) __
35° 34.276 N 80° 54.184 22,Certific ,
'W 10-16-23
6.Is(are)the well(s)f Permanent or Qfi'emporary Signaa c of Celli Well mmctor Date
By signing thisibrnt, I hereby ce•rtfi'that the well(s) Ives(we're')constructed in accordance
7.Is this a repair to an existing well: 0Yes or ONo with 15.,1 NCAC'02C'.0/00 or/5r1 NC.''IC 02C7'.0.?00 Well C'on.tvrucvlon Standards and that a
Il7his is a repair,Jill out known well construction i far nation and explain the nature of/lie copy ojdds record has hcen provided to the hell neater.
repair under 112/remarks section or on the back of thisforn.
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the saute 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 I GW-I is needed. Indicate TOTAL NUMBER of wells
drilled:
SUBMI'1'TAI.INSTRUCTIONS
9.Total well depth below land surface:565 MO
Pm.multiple tee/lc list all depths i/'elf//Irma(example.3(y)200'ane(2 rt/00') ons e ForAll Wells: Submit this form within 30 days of completion of well
constriction to the following:
10.Static water level below topor casing:50
If water level iserabove casing1 use (ft.) Division of Water Resources',Information Processing Unit,
6 1617 Mail Service C.ente ,Raleigh,NC 27699-1617
i 1.Borehole diameter: (in.) I
24b. For Injection Wells: in addition)o'sending the form to the address in 24a
12.Well construction method: above, also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,eta) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Uitthe gtioun(I Injection Conh of Program,
1636 Mail Service Centc ,Raleigh,NC 27699-1636
13a.Yield(gpm) 10 Method of test:AIR 24c. For Water Simply& Injection Wells: 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: Amotntt: completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-27.-201 G