GW1--00739_Well Construction - GW1_20240119

WELL CONSTRUCTION RECORD (GW-1) For Internal Use-Only: Print Form
I.Well Contractor Information:
RANDY OWNBEY
14,WATER ZONES f 1 ,
Well Contractor Name FROM To DESCRIPTION
3214A 349 ft. 350 ft.
ft. ft,
NC Well Contractor Certification Number
AIR DRILLING INC 15.OUTER CASING(for multi-eased Wells)OR LINER(ifap 'Kahle)
FROM TO DIAMETER TIIICKNESS I MATERIAL.
Corn Pt Y m Name 0 ft. 59 ft. 6 In. PVC
16892 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit//: FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable well cmisa•nr/inn permits(i.e. WC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. .in.
Water Supply Well: 17.SCREEN.
A ricultural FROM TO DIAMETER SLO't'SI•LE THICKNESS MATERIAL
DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) EllResidential Water Supply(single)
• ft. ft. in.
lndustrial/Conunercial DResidential Water Supply(shared)
• 18,GROUT'
liTigation FROM TO MATERIAL EMPLACEMENT ME'r11ODGAMOUNT
10u-WaterSupply Well: 0 ft. 20 IL GROUT POURED
Monitoring DRecovcry ft. ft.
injection Well:
—
Aquifer Recharge ft. ft.
q g DGroundwatcr Rcmediation
Aquifer Storage and Recovery Salinil Barrier 19.SAND/GRAVEL PACK(if applicable)
Y FROM To MATERIAL EMPLACEMENT METHOD
-Aquifer Test-
Experimental
Drainage ft. ft.
'
Experimental Technology O
Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attnch'adtlitional shcets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under//21 Remarks) FROM TODESCRIPTION(color,hardness,snit/rode hype,grain size,etc.)
0 ft. 49 ft. DIRT '
4.Date Well(s)Completed: 09-25-23 Well ID/I 49 ft• 365 ft.
ROCK'
5a.Well Location: ft. ft.
LAKEMIST HOMES It. It. -,.",,,�+ -.
'�.7` v g `•`l I!!Y I'-1.
Facility/Owner ft. ft.
" "r, E �«0 5,,,.5
Y Facility ID/I(if applicable)
152 RYLEIGH DAN,MOORESVILLE,N.C. 28117 ft. ft. JAN 1 9 2024
Physical Address,City,and Zip ft. ft.
IREDELL 4654791369 zl,REMARKS tn, ,, 't,^Etvn Pr,r..T;:'3 ``.,
County Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.Certi ion:
35° 31.195 N 800 49.520 W
9-25-23
G.Is(are)the tvcll(s) X I'crmancnt or QI'I'emporary Signature of Certified Well Contractor i Date
11y signing this form, I hereby certify that the iceil(s) was(were)constructed in accordance
' 7.Is this a repair to an existing well: DYes or ONo with ISA NCAC 02C.0100 or 1SA NCAC 02C.0200 It'el1 Construction Standards and that a
Phis is a repair•fill out known well construction it fmveation and evplain,the nature of the copy of ibis readrd has been provided In the irell owner.
repair ender 1/21 remarks section or on the back o/ibis••/m•m.
23.Site diagram or additional well details:
You may use the back of this page lo'.,provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the saute
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
365 SUBMI7"I'ALINSTRUCTIONS i ,
9.Total well depth below land surface: (ft•) 24a. For All Wells: Submit this foist,within 30 days of complelion of well
For multiple malls list all depths i/'diffe,•ent(example-.?«200'and 2 r,100') construction to the following:
10.Static water level below top of casing: 30 ft. ': .
( ) Division of1'• tier Resources,information Processing Unit,
If'rater lerc•i is above casing,use"+" 1617 Mail Service Center Raleigh,NC 27699-I 617
11.Borehole diameter:6 (in.) 241), For Infection Wells: in addition;to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: '
i.e,auger,rotary,cable,direct push,etc.) construction to the following:
( ger, I
, Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Centi r,Raleigh,NC 27699-1636
13a.Yield(gpm) 15 Method ol'test: AIR 24c. For Water Supply&Injection Wells: In addition to sending the form to
HTH the address(es) above, also submit one.copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016