GW1-2021-01987_Well Construction - GW1_20210527

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:( ��`/��/1C�
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14.WATER ZONES
Well Contractor FROM TO DESCRIPTION
N�
�0 ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
James Darby Well Drilling LLC FROM TO DIAMETER pTHICKNESS MATERIALt-7 ft. 7 ft. 6(� in. 15p W e -
Company Name 167959
16.INNER CASING OR TUBING eothermal dosed-loop)
2.Well Construction Permit#: FROM I TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) ft. ft. 1 in.
3.Well Use(check well'use): ft ft ; in.
Water Supply Well: FROM E TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural EJ Municipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft. ft. in.
j Industrial/Commercial []Residential Water Supply(shared) 18.GROUT
J Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 f -,-$'
i
_)Monitoring 13Recovery ft. ft.
Injection Well:
ft. ft.
1 Aquifer Recharge)Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery [Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
J Aquifer Test OStormwater Drainage ft ft.
Experimental Technology OSubsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soiltrock tyM grain size,etc.
RGeothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) fL L�ft
4.Date Well(s)Completed: �� Well ID# fL �O fL 5a.Well Location: 0 ft. wa ft.
Kapp Builders tom «a
Facility/Owner Name Facility ID#(if applicable) ft. ft.
528 Alex D. Owens Drive Kings Mtn. NC 28086 ft. ft. ,�-
Physical Address,City,and Zip ft. ft. )
Cleveland 21.REMARKS
County Parcel Identification No.(PIN) 2 f
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: o ' Unit
(ifwell field,one lat/long is sufficient) 22.Ce Ication' I�tS.,If� � P' '` do
' ll
®LYja J
N W e(& —X 2
6.Is(are)the well(s)�rmanent or ❑Temporary Signature of Certified Well 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: []Yes or ONo 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: 1/0 (N 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: Z J (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: (i..) 24b.For Iniection 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: construction to the following: f.
(i.e.auger,rotary,cable,direct push,etc.) G'
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ( I 0 Method of test: IQiLo` 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: P T G Amount: Z o 2_ 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