GW1--00728_Well Construction - GW1_20240119

WELL CONSTRUCTION RECORD GW-1 For •
1 �
Internal Use Only:
I.Well Contractor Information: I
RANDY OWNBEY
1
Well Contractor Name 14,WATER ZONES i
FROM '1.0 DESCRIPTION
3214A 389 ft• 390 II. 1 i -- "
NC Well Contractor Certification Number ft ft. I !
1
IS.OUTER CASING(for multi-ense'd ivells)OR LINER(if ap rllcable)
AIR DRILLING I N C FRo\i I To DIAMETER THICKNESS MA•IT.RIAL
Company Nome 0 ft. 59 fl. 16
I in. PVC _..._.__..
2022-9849 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit 1k FRO:M TO DIAMETER THICKNESS __MATERIAL
List all applicable well t•onslr•uctiun permits(i.e.U1C,County,State, Variance,etc.) ft. fl, i I in. `' "'
3.Well Use(check well use): ft. ft, ! 'in. `—
Water Supply Well: 17,SCREEN
LJAgricullural FRO.\I TO DIAMETER: `SLOT SIZE THICKNESS .M,crlRIA I.
IJMunicipal/1 ublic ft. fl. in. -
❑Geothermal(Fleming/Cooling Supply) IJResidential Water Supply(single)
dust'ial/Comntcrcial Waterfl• ft. h,:
0In
• ❑Rwidenliai Supply(shared)
I�IrrigaGon 18.GROUT i•
Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD tt AMOUNT
Non-Water Supply Well: 0 ft• 20 f•t. GROUT POURED
❑Monitoring ❑Recovery ----------
Injection Well: ft, ft.
❑Aquifer Recharge ❑Groundwater Remediation ft. rt.
L1Aquifer Storage and Recover 19.SAND/GRAVEL PACK(if applicable)
Y ❑Salinity Barrier Inloal TO MATERIAL EMPLACEMENT METHOD
[IAquiferTest ❑StormwaterDrainage ft. ft.
❑Experimental'l'echnology ❑Subsidence Control ft. ft.
DGcothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
LIGcothcrntal(Beating/Cooling Return) ❑Other(explain under#21 Remarks) FROM I O DESCRIPTION(cater,horsiness,soil/rock type,groin nice,etc_)
0 ft• 49 ft. DIRT ,
4.Date Well(s)Completed: 1-12-2023 \VelI ID/I 49 ft. 405 ft. ROCK
5a.Well Location: ft. ft. _
BRETT HEMPHILL — t. �"
_ ______ . o..,,bus'__
I'ncilily/OsvncrN,11e Facility lDl!(if applicttble) ft. ft. �, IAI`I n _..
126 SKI HAVEN PLACE,MOORESVILLE,N.C. 28117 ft. rt. J I1 �j�A_----_-_--_
Physical Address,City ant Zip
rt. ft. If .1[;:. '; a ia�t
IREDELL 46352861 12 21.REMARKS Er.V ,'_; —�__ ...
; f �' '
County Parcel identification No.(PIN)
-- _
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) —
35° 32.593 ,N 80° 54.424 22.eel rsre •
=
\' � •
1/12/2023
6.Is(are)the well(s): IJPermanent or ❑Temporary Signature ofCetll ed Well Contractorr Date
By signing this-Arm,I hereby certi/l'that the we/l(.sy was(were)constructed is accordance with
7,Is this a repair to an existing well: ❑Yes or CINo 154 NCAC 02C.0100 or 154 NC/IC 02C.0200 Well Construction Standards and that a cops'
Ifs/tis•is a repair,/i//out known well construction(*rotation(Ind exploit,the nature of the 4/'rlris record has been provided to the well owner.
repair under 112/remarks section or on the back of thisfbrat.
23.Site diagram or additional well details;
3.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction inks
const•tiction•only I OW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:, _
24.SUBI\1ITTAL INSTRUCTIONS
9.'1'ottl well depth below hand surface: 405
For multiple wells list all depths i/'d//Jrrent(example-.1@1200'and.?©100') (ft.) Submit this G\V-I within 30 days()TINT!'completion per the following:
24a. For All Wells: Original form to Division of Water Resources (L)WR).
I(1.Static water level below top of casing: 30
limiter level is above rasing,use'•+'•
00 Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
l I.Borehole diameter: 6 (in) 24b.For Injection Wells: Copy to DWR, Underground Injection Control(IOC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12,Well construction method: 24e.For\Vtitcr Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WA'l'ER SUPPLY WELLS ONLY: 24d.For Water Wells producing over I00,000 GPD: Copy to DWR,CCPCU,\
13a.Yield(gpm) 1 0 Method of test: AIR Permit Program, 1611 MSC,Raleigh,NC 27699-1 6 1 1
13b.Disinfection type: HTH Amount:
Form OW-I North Carolina Department of Environmental Quality-.Division of Water Resources
Revised 6-6:.01 S