GW1-2021-00658_Well Construction - GW1_20211222

—,r nt Form'
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES 4
Well Contractor Name FROM TO DESCREMON
tt tt &fkn-
lb t ft- ft Ay—
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased'wells OR LINER if a livable
James Darby Well Drilling LLC FROM To DIAMETER THICIINfFSS MATERIAL.
ft
ft. &I1 in '5 1 Z`)--\ V�---
Company Name 16.INNER CASING OR TUBING(geothermal closed400
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. It.
in.
3.Well Use(check well use): ft ft in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLAT SIZE THICKNESS MATERIAL
I Agricultural DJ Municipal/Public 0 ft ft in.
Geothermal(Heating/Cooling Supply) Xj Residential Water Supply(single) ft ft in.
I Industrial/Commercial Residential Water Supply(shared) 18.GROUT
11 Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: nft. f, &vkm 1a
DJ Monitoring ORecovery ft ft
Injection Well:
ft ft
J Aquifer Recharge QGroundwater Remediation
19.SAND/GRAVEL PACK if applicable
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
I Aquifer Test [3Stormwater Drainage ft ft
Experimental Technology 0Subsidence Control ft fL
!Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessa
1 Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCREMOTUeolor,hardness,solurock type,grain size,etc
D it tt D oJ,
4.Date Well(s)Completed: ' ' Well ID# ft % ft -To_/�Q I
5a.Well Location: ft ' ft VX:A1-
Frank Howey ft qb ft (,eC'r--
Facility/Owner Name Facility ID#(if applicable) ft ft
5904 Nesbit Rd, Waxhaw NC 28173 ft ft F
Physical Address,City,and Zip ft ft i 1
Union 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -
(ifwell field,one lat/long is sufficient) 22.Certification: 1,
N W f®�Oft'2l
6.Is(are)the well(s) XI Permanent or QI_J Temporary Signa of ertified Well Contractor Date
By signing this form,I hereby certify that the we//(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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
t
9.Total well depth below land surface: OLy\® 00 24a. For All Wells: Submit this;form within 30 days of completion of well
For multiple wells list all depths ifdiffereni(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 3 Z (ft) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+" 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 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&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:14062-- completion of well construction to'jthe county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016