GW1-2021-07851_Well Construction - GW1_20211102

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
`'� a,/ �� 14.WATER ZONES
S� FROM TO DESCRIPTION
Well Contractor N
.Z O ft. ft
4s5M-A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased welts)OR LINER if a livable
James Darby Well Drilling LLC FROM To DIAMETERTHICICNESS MAT,atIAL
® ft It.
t / is -2 V e
Company Name op
W21-0363 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM I TO DIAMETER TEncle ESS MATERIAL.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft ft. in.
3.Well Use(check well use): ft It. in.
17.SCREEN
Water Supply Well:
PP Y FROM TO DIAMETER SLOT SLZE TIHCKNESS MATERIAL.
I Agricultural OMunicipal/Public 0 ft, % in.
I Geothermal(Heating/Cooling Supply) X Residential Water Supply(single) ft. ft. in.
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
I Irrigation FROM To MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: k ft 1JL
Monitoring DRecovery ft. ft.
Injection Well: ft. ft
_I Aquifer Recharge DGroumdwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
:)Aquifer Test 13Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
i
FROM TO DESCRIPTION color,hardness,soillrock e, in size,etc.
Geothermal(Heating/Cooling Return) I Other(explain under#21 Remarks) ft ft.
4.Date Well(s)Completed: 10 7(4--21 Well ID# FL ft
5a.Well Location: ft ft.
Jonathan Hibbard f` ft
Facility/Owner Name Facility ID#(ifapplicable) ft FL
62 Ribbon Falls, Old Fort NC 28762 ft. ft. 021
Physical Address,City,and Zip ft. ft r n i:sZt i
McDowell 21.REMARKS ` ^
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IaUlang is sufficient) 22.Certificati n:
N W 'O
_0LQ4g4_,0
6.Is(are)the well(s) XI Permanent or ❑Temporary Signayz of Certi ed 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 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 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-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: 240 (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 1/4 (in.) 24b.For Iniection 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
139.Yield(gpm) 2D Method of test: blow 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: HTH Amount: (9 d 2 completion of well construction to the county health department of the county
where constructed. E
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016