GW1--00726_Well Construction - GW1_20240119

WELL CONSTRUCTION RECORD (CW-1) '
For internal We Only:
I.Well Contractor Inform ation: !I 1
1
RANDY OWNBEY
14.WATER ZONES 1 1 -I
Well Coo,rnctor Nome mom ro DisettttrriOv
3214A 429 ft. 430 - - -
NC Well Contractor Cerlificalion Number ft. ft' t .....
IS.OUTER CASING(for molt!-cased wells)OR LINER(if applicable)
AIR DRILLING I N C ritual TO DlAalE:rE:R1 TnlctNt1sS _ MATERIAL,
Company Name ft* 91 n. 6 ! tin. PVC
2022.-10195 16.INNER CASING OR TIMING(geothermal closed-loop)
2.Well Construction Permit)!: FROM TO _ WW.It Tl.R' 'rluct:Nlss MATERIAL
List all applicable n d!cousvrucrion permits(i.e.(IIC,Comm,,State, Variance,eta) ft. . ft. I, ;in. - ;
3.Well Use(check well use): fl. rt. in. - ----
Water Supply Well: 17.SCREEN 1
IAgriculunal ,. rBoat' To . --Dtnwt_:nat I sLOTsti.: _rtiic,t_Nt•ss .'lA'reitiA1.--.+
❑Municipal/1 Ublic ft. It, in,j
i !Geothermal(heating/Cooling Supply) I'IRcsidential Water Supply(single) -- :_...-----------__-_- --- _ -
I'I. -._.
ft. hi 1
1 IIndusu'ial/Co,nntere ill l I"(Residential Water Supply(shared) -- 1, --.-----__
I!IrrigaGort 18.GROUT --- -- -
CJWclls> 100,000 GPO FROM Ti) NIATnnim. EMrt.ACttaitCe-r METHOD x At•icii•N�i•Non-Water Supply Well: 0 fI. 20 fl. GROUT POURED
ElMonitorin1 IDReeovcry rt. n. 1 --- --
Injection Well:
[(Aquifer Recharge DGroundwater Remediation ft. ft. -
17Aqui tar Storage and Recovery C1Sulinily Barrier , 19.SAND/GRAVEL PACE(if»pplicable)
FRoal TO atA'rtstIAL EMPLACEMENT mE tot)
f_IAquilar'l est ❑Stormwater Drainage ft. ft. I
f_ll'sxperimentalTechnology EISubsidence Control ft. rt. --------
I!Geothermal(Closed Loop) f_l"I'racer ?U.DRILLING LOG(attach additional sheets il'necessary) �-
I:IGeothcrmal(Heating/Cooling Return) ClOther(explain under 1/21 Remarks) FROM TO -DESCRIPTION(color,hnrtlnes_s,soiUrusk ivpe,(ruigriic, 'c'.)
0 ft, 81 rt. DIRT
4.Date Well(s)Completed: 1`20-23 Well ID11 81 it 445 t•t' ROCK j I
5a.Well Location: ft, ft. li {
COPPER BUILDERS rt. ft. _ _
Facility/Owner Name Facility 1Ddl(it'applicablc) It• ft. j C y' ,--'; ^„r.. �_;
103 RYLEIGH DAN PLACE,MOORESVILLE,N.C. 28117 ' - - --
I'Itysical Address,City.and Zip rt. ft. - j , ��
IREDELL 4654687058 - _. �GZ4_
21.REMARKS i : '
Count Parcel identification No.(PIN) ' ' C)�"'Z. -`^('•�3 Lk"71
513.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1!
l it'well field,one Iat/ling is sufficient) 22.Cei'litic h:
•
35° 31 .039 N 80° 49.488 NN
et.;.4....._
1/20/2023
6.1s(are)the well(s): !!.!Permanent or ClToinporary Signature of Ceti' ed Well Contractor Date
By signing this farm,/hcreht'cervili'that lde,,rc1/(s)wan(were)constructed in accordance with
7.Is this a repair to an existing well: 17 Yes or LMIN° 15.4 NC:4C 02C.0/00 or/5,!NC.tc 02C;.0200 n'el1 Construction Standard,•and that a cola
1/'Ibis is a repair,fill out knoaar,tell cousrrtrcdon 1,1/br oration ct/explain the nature of the q/•lhds record hm been prorirled to the well owner.
repair under 1121 remarks section or on the bark of this•%nrm.
23.Site diagram or additional well details:
S.For Geoprohe/DPT or Closed-Loop Geothermal Wells having the same \0u may use theback of this page to'.provide additional well construction loll,
construction,only I GW-I is needed. Indicate"TOTAL NUMBER ol'wells (acid'Sec Over'in.Remarks Box).You nay also attach additional pages it'net essary.
drilled:
-- -^- - 24.SUBMI'l'TAL INSTRUCTIONS
• ,: ,
9.Total well depth below land surface: 445
For multiple odds list all depths ifi/iQivrnt(example-3?rr 200'and 2 n 100') (f l) Submit this GW-1 within 30(lays of well completion per the following:
50
(f
10.Static water level below top of casing: h) 24a. For All Wells: Original (room io. Division of Water Resources (DWR).
If'rater level is above rasing,,use"-I•' btformntion Processing Unit, 1617 MSC,Raleigh,NC 27699-I G 17
24b. For Injection Wells: Copy to D1VR. Underground Injection Control(IU('I
I I.Borehole diameter: 6 (in.)
Program, 1636 MSC,Raleigh.NC'2719-1636
12.Well construction method:
(i.e.auger,ratty,cable,direct push.etc.) 24c.For Water Supply and Open-Loup jGeothermal Return Wells:Copy Io the
county environmental health department of the county where installed
' #
FOR WATER SUPPLY WELLS ONLY: 24c1,For Water Wells producing over 100,000 GPD: Copy to DWR.(•C'PCl1:\
13a.Yield(gpm) 15AIR Permit Program, 1611 MSC,Raleigh,NC 27699-I61 1 •
(FI ) Method oftest: ,
. 1
13b.Disinfection type: HTH Amount'
Form(I W-I
North Carolina Department or Environmental Quality-Division of Water Resources Revised(i-G:(01 S