GW1-2021-00565_Well Construction - GW1_20210315

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
FROM TO I DESCRIPTION
Well Contractor Name`.� -,..1
�Z FS S' A 11? ft. 113 ft. rum q.�t.�1-�
z�
ft ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER(ifap livable
James Darby Well Drilling, LLC FROM TO DIAMETER THICKNESS MATERIAL
D ft 16 . in.
Company Name E H 19-06406
16.INNER CASING OR TUBIN eothermal dosed-loop)
2.Well Construction Permit#: FROM TO DIAMETER TRICKINESS I 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.
Water Supply Well: FROM CREE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ®Municipal/Public 0 ft. ft.
:J Geothermal(Heating/Cooling Supply) IgResidential Water Supply(single) fL ft, in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Itri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: B ft. ft ' eon
I Monitoring []Recovery ft. ft �-- yp
Injection Well:
ft. ft.
Aquifer Recharge []Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
_ Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
I Aquifer Test []Stotmwater Drainage ft. ft.
Experimental Technology []Subsidence Control ft. ft.
Geothermal(Closed Loop) []Tracer 20.DRILLING LOG attach additional sheets if necessary)
1 Geothermal(Hcating/Cooling Return) ElOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain sae,etc
j� o It. / ft. Rt� C/
4.Date Well(s)Completed:p�C�r T/„���42/Well ID# /s ft. .� ✓.z f ` e,/
5a.Well Location: ft ft ifo n 0°Lk
Robert Shoemaker a► fz.,4 s+4n
Facility/Owner Name Facility ID#(if applicable) ft 9,2 ft 0,g A-v .7'e
Lot 37 Luther Dr. Iron Station, NC 28080 M ft. � . �`�
Physical Address,City,and Zip ft. ft.
Lincoln 21.REMARKS
County Parcel Identification No.(PIN) gg
'i 30`.3riM3VU*'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certi cation:
N W 2`19—ao2-1
6.Is(are)the well(s)oPermanent or [ITemporary Siftdle of Certified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or X)No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
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 1 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: '` 'X (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(}00'and 2@100) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 1 A (in.) 24b.For Iniection 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) d Method of test:Blow 24c.For Water Supply&Iniection 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: S7/ 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