GW1--00718_Well Construction - GW1_20240119

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: Print Form
1.Well Contractor Information: I j•
RANDY OWNBEY
14;WATER ZONES I
Well Contractor Name FROM TO DESCRIPTION
3214A , 209 ft 210 ft' I I
ft. ft. I l
NC Well Contractor Certification Number
. AIR DRILLING INC FROAUTER CASINGT (for multi-cased
DIAMETER OR
THICKNESS MATERIAL
np a MArERIAI.
Company Name 0 ft. 60 ft. 6in. PVC
2023-27623 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C',County,Slate, Variance,etc.) ft. ft. 'in. �!
3.Well Use(check well use): ft. ft. ill.
I Water Supply Well: 17.SCREEN
FROM TO DIAMETER 1 SLO'I'SI''I,E THICKNESS MATEIRIAI.Agricultural Muuicipill/Public • ft. ft. in., -
•Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
ft. ft. in.
Industrial/Commercial OResidential Water Supply(shared)
18.GROUT •
Irrigation FROM TO MATERIAL. EMPLACEMENT METHOD A AM10UN'r
Non-Water Supply Well: 0 ft• 20 ft. GROUT 'POURED
Monitoring 0Recovery ft. ft. -'
Injection Well:
Aquifer Recharge ft. ft. ,
6 DGroundwater Remcdiation
Aquifer Storage and Recovery Salinil Barrier 19.SAND/GRAVEL PACK(If applicable)
y FROM TO MATERIAL ' EMPLACE\!ENT METHOD
Aquifer Test QStormwater Drainage ft. ft. I'
Experimental Technology DSubsidence Control ft. ft.
I.
Geothermal(Closed Loop) ©ITracer 20.DRILLING LOG(attach ndditional,sheets if necessary)
Geothermal(Heating/Cooling Return) DI'Other(explain under#21 Remarks) FROM To uttsCttlr ru)K(color,hardness,Bonn ocir t)tre,grain size.de.)
0 ft. 50 ft. DIRT'
4.Date Well(s)Completed: 10-26-23 Well ID# ft• 225 ft.
50 _amK '
5a.Well Location: ft. ft. I
LAKEMIST HOMES ft. ft. � , .� 7: i
Facility/Owner Name Facility IDII(if applicable) ft. ft.
121 SUMMERWIND DR,MOORESVILLE,N.C. 28117 ft. ft, Jhh1 L�Z�
Physical Address,City,and Zip It. ft. •t ,C;:„ '.I I i•;,,.•„t"£�:ng U-:
IREDELL 4639-70-2894 21.REMARKS if;,•(,'•,• A.1;:3
County Parcel identification.No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: _
Orwell liekl,one tat/long is sufficient) 22.Cer " ation `
35° 37.996 80° 53.641 -N W
10-26-23
6.Is(m e)the trell(s) X 1'ermanenl or ©I'1'empur:u y Signature of Certified Well Contractor I Date
By signing this Arm,/hereby eer*that Btu well(s)was(weer)constructed in accordance
7.Is this a repair to an existing well: DYes or DNo with/S,1 NCAC'02C.0/00 or ISA NCAC 02C.0200 IVell Construction Standards and that a
If this is a repair,fill oat known well consultation infbrnwtion and explain the nature of dre copy()Phis record has been provided to the well owner.
repair under 021 remarks.section or on the back ofdds form.
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 OW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
SUBMi'1"1'A1.INSTRUCTIONS I
9.'1'otal well depth below land surface: 225 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Far multiple wells list all depths ifdilli'rent(example-3 iil200'and 2 rr 100') construction to the following:
50
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
([water level is above casing,use"+" 1617 Mail Service Celtter,'Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b. For Infection Wells: in additiontoj sending the fora)to the address in 24a
above, also submit one copy of this fora, within 30 days of completion of well
12.Well construction method: constntction to the following:
(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) 30 Method of test: AIR 24c. For Water Snnnly S.: Infection Wells: In addition to sending the firm to
the address(cs) above, also submit one bopy of this ('Dana within 30 days or
13b.Disinfection type: HTH Amount: completion of well construction to theicounty health department of the county
where constructed.
Fora)UW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-2.2-2016
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