GW1-2021-00430_Well Construction - GW1_20210315

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
NGVb 5-Z' 14.WATER ZONES
WeI1COntractorNaIDe FROM TO DESCRIPTION
3I5-. ft it 6UGPr`�
NC Well Contractor Certification Number
15.OUTER CASING for multi�ased wells OR LINER if a livable
James Darby Well Drilling, LLC FROM T/O DIAMETER THICIQVESS MATERIAL
Company Name 10011835
16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits rt.e.UIC,County,State,Parlance,etc.) ft. M in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
J Agricultural DMunicipallPublic 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) J Residential Water Supply(single) fL ft, in.
Industrial/Commercial Residential Water Supply(shared)
18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. ao ft.
31 Monitoring 13Recovery ft. ft.
Injection Well:
ft. ft.
J Aquifer Recharge E)Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery [)Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E]Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) ElOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soiltrock type,grain size,etc
ft ft. r /f
4.Date Well(s)Completed: '° Well ID# 1 ft Cam(- ft. �j�cow
5a.Well Location: ft. ✓ ft.
Joseph Haubenhofer ft fL
Facility/Owner Name Facility ID#(if applicable) ft. ft.
16405 MacGregor Ln. Charlotte, NC 28278
Physical Address,City,and Zip ft. ft.
Mecklenburg 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.CertifiC lion:
�
N W a
e -2-
6.Is(are)the well(s)oPermanent or [3Temporary Sifnature of Certified Well Contractor Date
By signing this form,I hereby cenify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or E)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 I 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 if different(example-3@200'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 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) O Method of test:B10W 24c.For Water SunDly&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: Z- 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