GW1-2021-00363_Well Construction - GW1_20210315

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
FROM I TO I DESCREPTION
Well Contractor Name
,?.[SS'A / fL ft.
NC Well Contractor Certification Number o2 f 15.OUTER CASING for multi-cased wells OR LINER if a licable
James Darby Well Drilling LLC FROM TO DIAMETER THICIINESS MATERIAL
' e- ft 33 4r k in. SDQ_�l p V"c
Company Name
11-2020-141820 16.INNER CASING OR TUBING eothermal dosed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.
Water Supply Well: FROME TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipal/Public 0 ft. fa in.
Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft• ft. in.
Industrial/Commercial DResidential Water Supply(shared) I&GROUT
Irri ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: (9 ft 15 IL A 1 A v
Monitoring DRecovery ft. ft.
Injection Well: ft. fL
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage fL ft.
Experimental Technology Dsubsidence Control ft. ft.
RGeothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc
B L
4.Date Well(s)Completed:�—_Y- " Well ID# C f S fL A.Y (i'
5a.Well Location: 1 - 7 F fL Roe H4
Susan Kaylor S ft !a ft• 2w-►�i �o s
Facility/Owner Name Facility ID#(if applicable) L�f ft. 00 ft ny
5001 E US 70 Hwy Catawba, NC 28609 ft• ft. l
Physical Address,City,and Zip ft' ft' +
Catawba 21.REMARKS
County Parcel Identification No.(PIN) MAR
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 11 q Unit
0.191
(if well field,one lat/long is sufficient) 22.Certi n• ®V'JR SBCY'Gn q
N W &&;;� /c
a
6.Is(are)the well(s)ox Permanent or DTemporary Sign a of Certified Woll Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance-
7.Is this a repair to an existing well: Dyes or XX No with 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and thava
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may 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: 3oD (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@2200'and 2@100) construction to the following:;
10.Static water level below top of casing: O (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 1 A (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Rotary above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) /7 Method of test•Blow 24c.For Water Supply&Injection Wells: In addition to sending the form to
/ the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: FZ 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