GW1--00735_Well Construction - GW1_20240119

WELL, CONSTRUCTION RECORD (CW-1) For Internal Use Only: I
I.Well Contractor Information: I
RANDY OWNBEY I
Well Contractor Name 14,WATER ZONES I
1—±1t0\I__ TO IESC:11E'11 ON
3214A 390 rt 391 __,—__---_-...
NC Well Contractor Certification Number 605 f'' 606 fl. --� --" " '
j I
IS.OUTER CASING(for multi-cased/wells)OR LINER(nap licable)
AIR DRILLING I N C Glto, To.. DLMETER I THICKNESS __MATERIAL
0 rt, 75 f
Company NameI. 6 1 n, PVC
i
329772 TU6 -----___.__ ___
I6.INNER CASING OR BING(gci tlicrntat clused-loop) -
2.Well Construction Permit 11:
mom fro plAN:t1,T8R' Tittck):_tss at:crt•:Rlnt. I
List all applicable well construction permits(Le:WC:,County.Sure, Variance.etc..) ft. --ft ft. 1 in.-- - - -- - - I
3.Well Use(cheek st ell use): —
fl. rt. in. ., .
Water Supply Well:
17.SCREEN
❑!\'1'ie:ultut•a, mom '1_o DIA\1E titt • st.o'rstzt.-
•rnICKNISS �IA'1'I:ItIAI. -
6 OMunicipal/Ptiblic ft. R. in.I
IJGeothcrnull(Heating/Cooling Supply) I_'1Residential Water Supply(single) - — ___________......
It ft. M.
1;1Industrial/Commercial t:/Residential Water Supply(shared)
Cl IrrigationI8.GROUT -
CIWelIs> 100,000 GPI) FROM To I MATERIAL EMPLACEMENT METHOD.•A3unr IN'Non-Water Supply Well: 0 '''' 20 fi' GROUT POURED
--
r1Monhoring FIRecovery
Injection\Veil: .-__- __
i IAquilcr Recharge I:IGroun(itvalcl'Rcmcdiation R. _ . I't. - 1 .-_-
I
I',Aquifer Storage and Recovery 19.SAND/GRAVEL PACK(if applicable)
> II Salinity Barrier t+R0\I to 1 IATERIAI. EM PLACE CEMENT MEN IOD ---
LiAquiler'fest DStormwater Drainage ft. rt. i - - --
ORxperimental Technology ['Subsidence Control ft. ft. i;
['Geothermal(Closed Loo 1
P) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geotherni al(Heating/Cooling Return) LDOthcr(explain under 112I Remarks) FROMro DESCRIPTION(color,loudness,semracic t in.,milli'size,etc.)
p rt. 65 —rL DIRT I,
4.Date Well(s)Completed: 06-02-2023 Well Intl 65 f'' 805 f'_ ROCK i — — --
5a.Well Location:
AARON BRADSHAW It. rt. "�
.
I arility/Usvit t Name .___--__ A �—
facility IDIJ(il'upplicable) rt. n. 1 to--1 r:;:1:1
^: a _
367 MORROW FARM RD,STATESVILLE,N.C. 28677 ft. ft. , y 1;'"z•�� i Physical Address.City,and Lipr(, n. ' 1 9 3024 —
IREDELL 4703627249 21.REMARKS TT
County Parcel Identification No•(PIN)
;; t h_rota
51).Latitude and longitude in degrees/minutes/seconds or decimal degrees; -_--.-_.-_. _ ;
Orwell li d,one hulking is sufficient) I
35° 44.729 N. 80° 59.946 22.Cel tit : on:
\\ _ 6/2/2023
It.Is(are)the vell(s): t!iPermanent or CI'l emporary Signature of Get lied Well Contractor f
By signing this Arm,I hereby cerli/i•rho,the•lu•c//(s),1.0(,rr,•c)c,mstraeted in accordance with 7.Is this a repair to an existing well: I.IYes or CI No /5.1 A/C.'.-IC 02C.0100 or/5i1 NCAC 02C.0200 Well Construction Standards and that a copy
//•this is a repair.fill oat known well construction in/ornullion and explain due nature o/•rher n/'this record has been proridcd to the welt riwuer.
repair under 1121 remarks section or an the back of this form. (Hier.
-,
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
(add'See Over'in Remarks Box).You may also attach additional pages il'necessory.
construction,only I GW-I is needed. Indicate TOTAL.NUMBER dwells
drillcfl:._____________. __._ 24.SUBM'IT/\L INSTRUCTIONS
9.Total well depth below land surface: 805 • (ft.) j;
For multiple wells list all depths ifdi(/i•renr(example-3(rr)200'and 2(hl/00') Submit this G\V-I within 30 days of wall completion per(lie fallowing:
��•j
( I
I(I.Slalic wall','level below lap o1'casing: 3" ,.t) 24a. For All Wells: Original form jo;Division of Water Resources (MYRL
//'water level i.s above casing,use"+^ htl'ormalion Processing Unit, I(i17 MSC,Raleigh,NC 27699-I617
I
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: Copy to DWR, Underground Injection Control (ItIC)
Program, l636 MSC,Raleigh,NC 2709-i1636
12.Well construction cab ion cthod: 24c.For\Valet'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 WATER SUPPLY WELLS ONLY: 1
24d.For Water Wells producing over I(10,o00 GPD: Copy to DWR.CC'PCUA
13a.Yield cgpm, HTH2 Method ol'tesL AIR Permit Program, IGI 1 MSC.Raleigh,NC 27699-I6I 1
I3b.Disinfection type:' Amount: -
turn U W-I North Carolina Depm-t:uent of Environmental Quality-Division of Water Resources