GW1-2021-00522_Well Construction - GW1_20211222

WELL CONSTRUCTION RECORD (GW-1) 9 For Internal Use Only:
1.Well Contractor Information: II/I2/Z
/+ lje u :5-Ae-tz2 e 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
1 S' A rr. ► ��„�o d K
rr. rt.
NC Well Contractor Certification Number (� 15.OUTER CASING forinalti-cased wells OR LINER:if a "licable '
James Darby Well Drilling, LLC FROM TO DIAMETER THICKNESS MApTERIAL
d ft. q3 ft. / i in. Sap aZI / ��
Company Name 13413 `N
16,'INNER CASING OR TUBING' eothermaf closed-too'
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well consirtiction permits(i.e.UIC,Couniv. ';late, t%wvance,elc) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public A 0 ft. I U�ft. in.G /G /�jZ_�(,o (/�
eothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18•GROUT
- Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. a 7., ft. 4d lie 1
0
1 J T O u
Monitoring 0 Recovery ft. ft.
Injection Well:
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if Applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
RGeothermal(Heating/Cooling Return) 0tth-er(explain under#21 Remarks) � ft. 7 ft. fz e� 011
AV
4.Date Well(s)Completed: //-9-•�MVell ID# 7 ft. �Z ft. �J n A„ ,
5a.Well Location:
William R Homes ►L ft. 3n3 ff• rz
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1055 Lakefront Woods Dr. Belmont, NC 28012 ft. ft.
Phvsical Address,City,and Zip
Gaston 21.REMARKS
WO L2 I
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.Cer cation:
N W 9;;2a2/
6.Is(are)the well(s)ox Permanent or Temporary Signature of Certified 11 Contractor Date
By signing Ihic./Ornt, I herebv cerli/y that the wellO was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or No wilh/5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If/his is a repair ill out known well construction information and explain the nature a/'Ihe cape gl'this record has been provided to the well owner.
repair raider..21 remarks section or on the hack a/this/ornr.
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: 303 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
b'or multiple wells list all depths ifdiffereni(example-3@200'and 2L�tn/ll0)' construction to the following:
10.Static water level below top of casing: //y (ft.) Division of Water Resources,Information Processing Unit,
I/water level is above cabin,(,use"� P 1617 Mail Service Center,Raleigh,NC 27699-1617
1.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) �/2 Method of test: Blow 24c. For Water Supply& Infect on 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: ( 02— completion of well construction to the county health department of the county
where constructed.
Fonn GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-201.6