GW1-2021-03660_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
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1.Well Contractor Information:
htL.rvie, 0%Ck\01J 14.WATER ZONES AX
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
NC Well Contractor Certification Number se
15.OUTER CASING for maltitased wells TOIL if a livable
James Darby Well Drilling, LLC FROM TO DIAMETER T.Hr=SS MATERIAL
Company Name ft �� ft in. .�
13392 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) k. ft. ! in.
3.Well Use(check well use): ft ft in.
Water Supply Well: FROMCREE TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
_i Agricultural ®Municipal/Public U ft. ft. in;
_J Geothermal(Heating/Cooling Supply) 13Residential Water Supply(single) ft. ft. in
J Industrial/Commercial Residential Water Supply(shared) 18.GROUT
X]Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft' ?-0 ft
J Monitoring Recovery ft. ft
Injection Well:
ft. ft.
]Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK ita livable
_I Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
3J Aquifer Test DJ Stormwater Drainage ft ft.
1 Experimental Technology Subsidence Control ft. ft.
1 Geothermal(Closed Loop) O]Tracer 20.DRILLING LOG attach additional sheets if necessary)
El Geothermal(Heating/Cooling Return) J Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soillrock tym grain size,etc
C) ft' 8 ft. c1
4.Date Well(s)Completed:5' t/' ( Well ID# 96 ftItfL -Vq�—
5a.Well Location: /It ft, a-k (-5 try W ew--k ` `9.0C'IP--
Caroline & Josh Bogen A Ck It. fL
Facifity/Owner Name Facility ID#(if applicable) ft. ft.
391 Glen Arbor Dr. Belmont, NC 28012 ��� -
Physical Address,City,and Zip ft ft. °�xs
Gaston 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in d revs/minutes/seconds or decimal degrees:
g � �
(if well field,one lat/long is sufficient) 22.CertifiiC lion:
N W
6.Is(are)the well(s) xi permanent or OTemporary Signature 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: Yes or J 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
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9.Total well depth below land surface: O (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,
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) 50 Method of test:Blow 24c.For Water SUDDIV&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: T�- completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016