GW1--00727_Well Construction - GW1_20240119

l
WI+,IJIJ CONSTRUCTION RECORD (G 1)W—
For Internal Use Only: I, ;
1.Well Contractor Information: I.
RANDY OWNBEY I I
Well Contractor Name 14,WATER ZONES I I --I
FROM '1'0' . DESCRIPXION
3214A 489 rt. 490 I'h
— ---
\'('Well Contractor Certification Number 11• ft. I I - -
A I R DRILLING I N C IS.OUTER CASING(for nntltt-easedlwetls)OR LINER(if aultc;ible) ----.1
RRO\I nl:\m1;f1;R; THICKNESS MATERIAL
Company Name 0 IL 80 n 6 in. PVC - -.
2022-10329 IS.INNER CASING OR TUBING(gebtliernlat closed-loop) -1
2.Well Construction Permit II. P1t051 _TO it I.t 'rrlt t I Inci: rss �1:�'rLyt�A�. —
I_ist all applicable well construction permits(i.e.U/C.•,CoutaK State, Variance,etc.) ft. - — - .....__ ._.. - _ - -
fl. I, in. -
3.Well Use(check well use): ^ - rt, rt, p in.
Water Supply Well: '' --
17.SCREEN •,
L7/\gflelllhtlill FROM TO DI:\\it(rEte 1 SLOT SIZE THICKNESS >tAATERIAI.—
❑Munieipal/Public rt. ft. in.
Lioeothermal(Ileating/Cooling Supply) l_IResidential Water Supply(single) ---`--.-------.....-_--
11. ft. in.
(_]Industrial/Commercial ❑Residential Water Supply(shared)
I�Irri nnioll (S.GROUT
e, 0 Wells> 100,000 GPD FROM TO mATIiRIA1• EMPLACEMENT METHOD,e AMOUNT Nan-Water Supply Well; 0 fL 20 11. GROUT ; POURED
❑Monitoring ❑Recovery ft. -- ft. '
Injection Well: I,
DAquifer Recharge ❑Groundwater Remcdiation t' it. ''
li
'IAquifbr Storage and Recover 19.SAND/GRAVEL PACK(If applicable)
Y DSalinity Barrier FROM TO NI,\TERIAL EMPLACEMENT t \CI_att\\'r n_irruou
i i:\quilcr'lest DS tormwater Drainage ft. ft. i
I
ilisperintental Technology ❑Subsidence Control ft. ri. — - ---
i :Geothermal(Closed Loop) I..hll'accr 20.DRILLING LOG(attach additional sheets if necessary)
L.iGcolherrrtal I I lentiug/Cooling Return) L7Uther(explain under 9.21 Remarks) _ROM ''ro DESCRIPTION(color_hardness,ssfl/oich i;pe.groin sizgri:1 ..
1-18-23 0 ft, 70 ft• DIRT
4.Date Well(s)Completed: Well Ill!/ 70 f'• 505 '•'• ROCK ---
-
5a.Well Location; H. H.
COPPER BUILDERS rt. rt. —— —'
�•;: - 'il. r.teiliiy/Owner Name Facility ID/ (i'applicnble)
I -- 4 _ I
104 RYLEIGH DAN PLACE,MOORESVILLE,N,C. 28117 ft. 1'1• L. �' ""c'="g.
,1 y _ '.- -
Physical Address,City,and zip
rt. fl. 9[G?
IREDELL 4654782262 21.REMARKS Ini.. -
County PareelidentificationNo.(PIN) , =r3;; rMk
5b.Latitude and longitude in degrees/minutes/Seconds or decimal degrees:
(iCoalI raid.one tat/font,is sufficient) 22.CCPli1j OIL' -------e. ..7,7 1
- -
35° 31 .044 N 80 ° 49.471 w
1/18/2023
G.Is(are)the well(s): ClPermanent or ❑Temporary Signature of Certified Well Contractor Date
UP signing this./brut,//w,','hv ecrti(i'drat the rre/l(.e)was(were)c onsuvcled ill aeenrdunee a ith
7.is Iltis a repair to an existing well: [Wes or h1No LS;I!VC..,ICC 02C.'.(1100 or MI A'C':If'02C.0200 Irel1 Cann/wilt,'Simulants mai,/r,a a rupr
/1 i/us A.a r,•puir,./ill out/monw,roll c•anxn'uction i/cm,atiau and avian,the nurture q/'thc of:this reca,•d has heavy provided to the cell owner
rrpuir Maier u.'.l remarks section or an the back q/•this./nrm.
23.Site diagram or additional well details:
S.For Geoprobe/DP'1'or Closed-Loop Geothermal Wells having the same
may use the back of this page to provide additional well construction kilo
construction,only I GW-I is needed. hid cute TOTAL.NUMBER of wells (add'Sec Over'in Remarks Box).You May also attach additional pages II'necessary.
drilled;
' 24.SUBMITTAL INSTRUC'I•IONS I
9.Total well depth below land surface: 505 (ft.)
I•braa tiple irclls list all depths i/'dUi,'a.nt(example-.1 n 200'and 2191/0(lqSubmit this Gb\'-1 within 30(lays of well completion per the following:
(fL) 24a. For All Wells: Original form to Division of Water Resources (DWR I.
10.Static water level below top of casing: 50
limiter level is above casing,use"•I- Information Processing Unit, 1617 MSC,Raleigh,NC 27699-I G 17
i 1.Borehole diameter: 6 (in,) 24b.For Injection Wells: Copy to DWR, Underground Injection Control (IlJ(')
Program, 1636 MSC,Raleigh,NC 27(AI9-1636
12.Well construction method:
1i.e.auger,rotary,cable,direct push,etc.) 24e.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 1
24d.For Water Wells producing over 100,000 GPI): Copy to DWR,C:C:PC•UA
13a,Yield(glint) 12 Method ol'test: AIR Permit Program, 1611 MSC,Raleigh,.NC27G99-1G1 I
13b.Disinfection type: HTH Anu)unL:
Form G W-I North Carolina Department of[Environmental Quality-Division of Water Resources , Revised(r-r.•Ji IN