GW1--00731_Well Construction - GW1_20240119

WELL CONSTRUCTION RECORD GW-1 ForI Print Form
I Internal IJsc Only:
1.Well Contractor information: ;
RANDY OWNBEY
14.WATER ZONES
Well Contractor NameI I
FROM 'I'O DESCRIPTION
3214A 189 rt' 190 rt'
NC Well Contractor Certification Number ft. ft.
AIR DRILLING INC 15,OUTER CASING(for multi-cased wells)OR LINER(if ap Itcable)
FROM ' 1_1'0 DIAMETER THICKNESS MATERIAI.
Company Name 0 fl. 97 ft. 6 in.
329286 16.INNER CASING OR TUBING(geothermal closed-loop) PVC
2.Well Construction Permit#: FROM To DIA\1E t'ER THICKNESS MATERL\I.
List a//applicable wet/construction permits(i.e. WC,County.State,Variance,err.) ft. ft. in. — —
3.Well Use(check well use): ft. ft. in. — "—
Water Supply Well: 17.SCREEN
�A(?I'ICIIhUfal FROM TO DIAMETER SLOT SIZE THICKNESS MATERIALOMutticipal/Public ft. ft. in,
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single)
lndustriaUCommercial DResidential
ft, in.
Water Supply(shared)
hligation 18,GROUT ,
FROM TO MATERIAI. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 20 ft. GROUT
Monitoring POURED
�Rccovcry ft. ft.
Injection Well: -
Aquifer Recharge Groundwater Rcmcdiation ft. ft.
Aquifer Storage and Recovery ❑SRlinity Barrier 19.SAND/GRAVEL PACK(if applicable)
FROM "TO MATERIAL MI'LACI(atENT\IETItUn Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology OSubsidenee Control ft. ft,
Geothermal(Closed Loop) �'1'racer 20.DRILLING LOG(attach additional sheets if necessarEy)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM
0 t o DESCRIPTION(cedar,Hardness,sail/rock type,grain size.ere.)
ft* 87 fL DIRT
12-6-23
4.Date Wells)Completed: Well ID# S7 —
ft. 205 n• ROCK
Sa.Well Location: ft, It.
PRINCETON HOMES rt. (,, _ — _.
Facility/Owner Name — "
FacilityIUII if a ft. ft. '=� .,,,,+ ; I '':...(-'.
139 TRENT PINES,MOORESVILLE,N.C, 28117 ft. ft. JAN 1 Q 7
Physical Address,City,and Zip ft. ft. ���
IREDELL 4639310401 21.REMARKS lfls.:r:r mac-,t 7fC- ,c.k'-
VW County Parcel Identification No.(PIN) r"JL
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Orwell field,one IaUlong is sufficient) --
22.Ccrtifrdn:
35° 38.092 80° 54.513 ;
N W I.
j'�'�'= _ 12-8-23
6.Is(are)the ttell(s)JX Permanent or D'Pemporary Signature of Cc died Well Contractor Date
lip.signing this farm.l hereby certi/v that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 0Yes or ONo with/SA NCAC 02C.0100 or ISA NCAC 02C'.0200 Well Construction Standards and that a
if this is a repair,fill out known well construction in fornurlinn and explain the nature of the copy of ids•record/has been provided to the well owner.
repair tinder'VI remarks section or on the back of this for•w.
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same Youmay use the back of this page to provide additional well site details or well
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: _ —
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 205 (ft.) 24a. For All Wells: Submit this f'oi'm within 30 days of completion of well
l:nr multiple hells list a/I depths iifdUliren,ieram0,lt'-.I[J200'and 2 a/00')
construction to the following:
40
10,Static water level below top of casing: (ft.) Division of Water Resources, Processing
If niter level is above casing,use•'+' Information Unit,
1617 Mail Service Cetttcr,.Raleigh,NC 27699-1617
11,Borehole diameter: 6 (in.)
24b. For infection Wells: In addition'to sending the form to the address in 24a
12.Well construction method: above, also submit one copy of this f(inn within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
I3a.Yield(gpnt) 12 Method of test:AIR 24c. For Water Sunup' &Injection Wells: In addition to sending the from to
Me address(es) above, also submit one copy of this Iorrn within 30 (lays uI'13h.Disinfection type: HTH Amount: completion of well construction to the;county health department of the county
• where constructed. I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-7.7.-7.0 16