GW1--00736_Well Construction - GW1_20240119

WELL. CONSTRUCTION RI�'.0 ___ GW-1 l Print Form.
Fur Internal Use Only: I
1.Well Contractor Information:
RANDY OWNBEY
14.WATER ZONES I i
Well Contractor Name FROM TO DESCRIItr,ON
3214A 449 ft. 450 ft.
- -`-''NC Well Contractor Certification Number
ft. I I
q
AIR DRILLING INC IS.OUTER CASING(for multi-casedlwclls)ORLiNER-(ifap ricable)
FROM TO DIAMETER r THICKNESS MA'1'IiliIAI,
Company Name 0 ft. 55 fL 6 i n.
PVC
2023-14875 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit II: FROM TO DIAMETER I THICKNESS MATERIAI,
List all applicable well construction permits(i.e. WC',County,State, Variance,eta.) ft. ft. d in.
" -
3.Well Use(check well use): ' ft. • ft. in.
I Water Supply Well: 17.SCREEN I '
QAgriculu.;rl ) FROM TO _ IMAMETER SLOT SIZE TIIICKNF.S MATERIAL
Municipal/1 ublic ft. —ft. in. -
Geothermal(Heating/Cooling Supply) X�IResidential Water Supply(single) -' ____-
Industrial/Commercial Water Supply(shared)
ft.
inigalion 18.GROUT •
FROM 'f0 ft. in.
\7 A'rFRL\I, EMPLACEM ENT at t:rtlot,R AMOUNT
Non-Wafer Supply Well: o ft. 20 fi.
GROUT POURED
Monitoring Recovery It. ft.
Injection Well:
Aquifer Recharge [ Glroundwalcr Remediation ft. ft.
Aquifer Storage and Recover 19,SAND/GRAVEL PACK(if applicable)
Y DSalinity Barrier FROM TO MATERIAL E\IPL.\CE\iF:N'1'\fFa'IIUU
Aquifer Test DIStotntuatter Drainage ft. ft.
Experimenlal'fcchnology DiSuhsidence in under
ntil ft. --ft.
Geolhermal(Closed Loop) Q'fracer 20.DRILLING LOG(attach additional sheetsif necessary)
Geothermal(Floating/Cooling Return) DOther(explain under'!/21 Remarks) FROM TO DEscRD'•I•tON(color,hardness,sou/roel(n w..raio size,ete.i
0 ft. 45 It. DIRT
4.Date Well(s)Completed: 06-28-23 Well IDll 45 ft. ft. �-
465 ROCK
Sa.Well Location: R. ft.
LAKEMIST HOMES - ft. -" ft. d t =. ,
Facility/Om ierName Facility IUII,(if applicable) It• ft. : 3-4y , r-_
145 RYLEIGH DAN , MOORESVILLE,N.C. 28117 (0. ft. --� ---------
1; ,1�;1>>1 g �G24
Physical Address,City,and Zip ft. ft. ---
IREDELL 4654695120 21.REMARKS•
;; Ifl v"'�'!'��63r�C;r '
M- C,:;OG
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degreesIminules/seconds ordecimal degrees: I, --
(if well field,one ladlong is sufficient) 22.Certif' on:
35° 31.165 80u 49.568
N W
6-28-23
6.Is(are)the well(s)OX Permanent or ❑ITentporary Signature of Cc dint Well Contractor, Dale
l3v signing dui form, I hereby centfir that the well(s)one(were)constructed in aCCO,YI(aC('7.is this a repair to an existing well: Dyes or DNo with 15,4 NCAC'02C.0100 or 154 NC1IC 02C'.0200 IVell Construction Standards and thou a
//'This is a repair,Jill our bunt?,moll construction iri/irrararion and c-splain the nature of the "IV of dris•record has been provided to the irehl antler•
repair under i121 remarks section or on due back q/'this Arm.
I
23.Site diagram or additional well details:
You may use the back of this page to'providc additional well site details or well
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only l GW-I is needed. Indicate TO'I'A1,NUMi3GR of wells constnuction details. You may also attach additional pages if necessary.
drilled:
-- -_____, _ •
SUBMITTAL,INSTRUCTIONS !, ,
9.Total well depth below land surface: 465 (ft•) 24a. For All Wells: Submit this forrit within 30 days of completion of well
For mtdlip/c wells Hsi n11 depths if diploid(example-3(i0200'and 2@100)
construction to the following:
10.Static water level below lop of casing: 50
if now level is abort'crazing,use"1" (ft.) Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11,Borehole diameter: 6 (in)
24b. For Infection Wells: in additionksending the Mini to the address in 2lla
12.Well construction method: above, also submit one copy of this formt 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,Underglround Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 35 Nletho(I of test: AIR 24e. Frig Water Supply S: I)jection Wells: In addition to sending the form to
the address(es) above. also submit one copy of this form within 30 days of
HTH •
13b.Disintectiot type: Amount: completion of well construction to the county health department of the county
where constructed.
•
Form OW-I North Carotins Department of Environmental Quality-Division of Water Resources
Revised 7.-27.-7.01 6