GW1-2021-03821_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
FROM To DESCRIPTION
Well Contractor Name
1 v ry w rr. rt.
NC Well Contractor Certification Number 1 15.OUTER CASING for multi-cased wells ORIN LER"if a licable
James Darby Well Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
ft. 1 1 I rt. G IC in. D k_
Company Name 16.-INNER'CASING OR TUBING(geothermal closed-loop) 1-
2.WCII Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
l.isl all applicable well construction permits(i.e. 1/IC,County,Stale, I7irtance,etc) Tt. ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public 0 ft. tt. ini
Geothermal(Heating/Cooling Supply) E)Residential Water Supply(single) ft. ft.
Industrial/Commercial Residential Water Supply(shared) 18.';GROUT
lrrl at10n FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: b rt. ' ft. d Ie; fi/o v t2
Monitoring Recovery
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color•hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) E Other(explain under#21 Remarks) fr. � tt. �� e l
ALI
4.Date Well(s)Completed: L—j —All Well 1D# j ft. c�e ". 4 Yoko L. ( N
5a.Well Location: (lo
' ft.
Schumacher Homes l b S ft' 3 Yoft
Facility/Owner Name Facility ID#(ifapplicable) Et
:
13701 Petworth Ct., Charlotte NC 28278 3 2
Physical Address,City,and Zip ft. ft. _ F Wit
Mecklenburg 21 REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.Cert• "ration:
s -
N W it
6.Is(are)the well(s) Permanent or OTemporary Si na re o Certified I Cot tractor Date
By signing lhis/iirrn. I herehv,cerli/i,Ihal the well(s) was(were)constructed in accordance
7.Is this a repair to an existing well: Oves or E)No with 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well('onsN'uclion Standards and that a
y this is a repair,fill out known well construction hil'o•nialion and explain the nolure of the copy o/this record has been provided to the well owner.
repair under 21 remarks section or on the back of this farm.
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-I is needed. Indicate TOTAL NUMBER ofwells construction details. You may also attach additional pages ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 q2) (ft-) 24a. For All Wells: Submit this° form within 30 days of completion of well
hor mulliple wells list/all depth ifdi�%erent(e.rample- (�i 2(/0'anc/2�1110') construction to the following:
10.Static water level below top of casing: ! (ft.) Division of Water Resources,Information Processing Unit,
h'water level is above casing,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For Infection 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: 11e4A-!�V construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLv WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 94 Lc/ 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: A17TW Amount: 7 o Z 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