GW1-2022-03082_Well Construction - GW1_20220307

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Co tractor Informatio E
14.WATER ZONES
Well Contracto me FROM TO DESCRIPTION
n l -4
ale
NC Well Contractor Certification Number
15.OUTER CASING for multi ed wells)OR LINER if applicable)
James Darby Well Drilling LLC FROM To DIAMETER THICKNESS MATERIAL
aft. /0/ ft. IAVj�
Company Name v'�Stn. Ale.
13492 16.INNER CASING OR TUBI(NG� other al closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft- R in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SUE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. fa in.
:]Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. it. in,
Industrial/Commercial DResidential Water Supply(shared)
.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0
ft. ft. T
:)Monitoring DRecovery ft. it
Injection Well: ft to
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Auifer,Test q DStormwaterDrainage
Experiitnental Technology DSubsidence Control
Geothermal(Closed Loop) DTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) F1 Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness,sontrock gain size,etc
D ft. ft. �d s�,/
4.Date Well(s)Completed: Well ID# ft. ft-
5a.Well Location: ft. ft.
L&M Construction
Facility/Owner Name Qas{�a Facility m#(if applicable) ft. O ft. ftiTz
ry
620 Unity Church Rd. Kingpin, NC 28086 ft. ft.
Physical Address,City,and Zip ft. ft.
/ 21.REMARKS _.
roouni; �v Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certification: t y 4y,`�t�,a�
id1���`�.�.li 1 rI.MI
6.Is(are)the wells) X Permanent or DTemporary 7,,g.,,,'
tore ell on org this form,I her cert fy that the well(s)was(were)constructed in accordance
} 7.Is this a repair to an existing well: Dyes or E)No with 15A NCAC 01C.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-1 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: �(IeII (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and�2@1001 construction to the following:
10.Static water level below top of casing: •' (fL) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1 A (in.) 246.For Injection 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 A r 1// 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: completion of well construction Ito'the 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