GW1-2021-00566_Well Construction - GW1_20210315

WA CONSTRUCTION RECORD GW-1 For Internal Use Only:
1.Well -u actor Information:
y\,'r\-, L D S 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
2 '1ft. ft.
ft ft. 11)v`
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LINER if a livable
:,James Darby Well Drilling, LLC FROM TO DIAMETER THICKNESS MATERIAL.
ft. ft ll in.
Company Name 5h(�a` PVC
E H 2O-07345 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft- fL in.
3.Well Use(check well use): fr' ft. in.
Water Supply Well: FRO CREE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipallPublic 0 ft, ft. in.
Geothermal(Heating/Cooling Supply) x)Residential Water Supply(single) ft• ft. in.
:)Industrial/commercial DResidential Water Supply(shared) 18.GROUT
1rri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft & l�Q
Monitoring QRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft
Experimental Technology DSubsidence Control ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
RGeothermal(Heating/Cooling Return) ElOther(explain under#21 Remarks) I
FROM TO DESCRIPTION(color,hardness,soWrock type,gnin size,etc.
4.Date Well(s)Completed: k - d- Well ID# ft' V ft-
5a.Well Location: ft ft aWA
it Sandra Lee G ,1 it• 73rcnw, we,..,-J P'---12
Facility/Owner Name Facility lD#(if applicable) 71 y ft' ft'
695 S. Ingleside Farm Rd Iron Station, NC 28080 ft' ft. -� a?;•;/:�a'i
Physical Address,City,and Zip
Lincoln 21.REMARKS
County Parcel Identification No.(PIN)
Unit
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certifica'on:
w //��
N W �`�V
6.Is(are)the well(s)[x Permanent or OTemporary i ture of Certified Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes 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-1 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: (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3 a 0'and 1@100) construction to the following:
10.Static water level below top of casing: So (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 1/4 (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 27699-16M
13a.Yield(gpm) O Method of test'Blow 24c.For Water Supply&Infection 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: 1 607— 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