GW1-2021-07847_Well Construction - GW1_20211102

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
FROM TO I DESCRIPTION
Well Con6ctor Name
ft. ft.
A ft. fit.
NC Well(Stitractor Certification Number
V 15.OUTER CASING for wells OR LINER if apilicable)
James Darby Well Drilling, FROM TO 7 21-R MATERIAL
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#:EH20-03627 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC,County,State,Variance,etc.) ft• ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well: FROM TO.- DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public 0 in.
ft.
31 Geothermal(Heating/Cooling Supply) E ft ft
)Residential Water Supply(single) V
. . in.
:]Industrial/Commiercial OResidential Water Supply(shared) _18.-GROUT
11nigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: (9 ft 2 0 ft. A4, '0/0j g
3Monitoring [3Recovery ft. ft.
Injection Well: ft. ft.
3Aquifer Recharge [)Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERUL EMPLACEMENT METHOD
3 I . ft.Aquifer Test DStormwater Drainage ft
:i)Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) []Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FIGeothermal(Heating/Cooling Return) ElOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiltrock tyM grain s4e,etc.)
0 1 5� ft. 0 /K,-,4
etc
/ ID# ft' OROW/t,
4.Date Well(s)Completed: 1,� w?
5a.Well Location: V 9 ft. 7 X
Christopher 013rien 7? ft- ? ,9 fL 5',l FT
Facility/Owner Name Facility ID#(if applicable) '/-0 fL -2--0-�fL el"C
No # yet Bridge Way Denver, NC 28037 .22Pt- ;2 ?SfL sor-_r saw fZue V­
Physical Address,City,and Zip I&sft- 3 2 d
Lincoln 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.Certifii_q0tion:
6.Is(are)the well(s)oPermanent or OTemporary Sighafide of Certifie'dW_ell tractor 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: aver or XI 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 ofthe copy of this record has been provided 16 the well owner.
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional w I ell details:
8.For Gcoprobe/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 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,
lfwater level is above casing,rise"+" 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 I 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) 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
i
13b.Disinfection type: HTH,No Amount: '7 o-2- completion of well construction to the county health department of the county
where constructed. i
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016