GW1-2022-03086_Well Construction - GW1_20220307

WELL CONSTRUCTION RECORD (GW-1) 1 For Internal Use Only:
1.Well C tractor Inf motion F"/mil /Z, Z
H i
14.WATER ZONES
FROM TO I DESCRIPTION
Contmct rName 7
� I ,fit• /S/ ft �i w TG� o/�C
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
James Darby Well Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
ft. O It. in.
Company Name
16.INNER CASING OR TUBING eother al closed-loop)
2.Well Construction Permit#: a V FROM TO DIAMETER THICKNESS AL
MATERI
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.
Water Supply Well: 17.SCREEN
PP Y FROM TO DIAMETER SLOT SIT£ THICKNESS MATERIAL
Agricultural [:]Municipal/Public ft ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
1 Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft 010 ft
j Monitoring DReGovery tt. ft
Injection Well: ft. ft.
]Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
I Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test C)Stormwater Drainage ft. ft.
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) [3Tracer 20.DRILLING LOG attach additional sheets if necessary)
RGeothermal(Heating/Coofing Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION color hardness,soiurock a in sir etc
tt. O ft.
4.Date Well(s)Completed: Well ID# go
tt ft �QWh 5 /
5a.Well Location: ft ft
IL
Facility/OOwner��Na��me Facility ID#(if applicable,)/n ft ft /
lft. ft.
Physical Address,City,and'Zip / ft. ft.
21.REMARKS r m
n �
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: _
(if well field,one latflong is sufficient) 22.Certili tion: °��9T
�rr 4r::r.=�;1 k
N W rr: i .�i �r Gyl�'_
"14d 9/1.k
6.Is(are)the well(s)OPermanent or OTemporary 7Bsigning
re o C rfied Well Con led
a
t is form,I hereby c that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well• EI Yes or E]No A NCAC 02C.0100 or IAC 01C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature ofthe copyojthis record has been pro o 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
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 ijdifferent(example- Q200'and 2@10001 construction to the following:
10.Static water level below top of casing: J (ft.) 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.) 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
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: 5 dZ completion of well construction to 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