GW1-2022-04453_Well Construction - GW1_20220502

1-111 Il 1 VI 111
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
G�Lt2 Ley 14.WATER ZONES I
Well Contractor Name FROM TO DESCRIPTION
ft
Dr fL vs
3121 1ZZ . z> � fc
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if ap livable
James Darby Well Drilling LLC FROM I To I DIAMETER THICKNESS MATERIAL
ft ft � _in. ' C—
Company Name
10012843 16.INNER CASING OR TUBING" eothermal closed-loopi
2.Well Construction Permit#: FROM To I DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(r.e.UIG County.State, Variance,etc.) It. fL 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 ft. ft_ in.
Geothermal(Heating/Cooling Supply) OC Residential Water Supply(single) ft. It. in.
Industrial/Commercial Residential Water Supply(shared)
18.GROUT
Irri ation FROM TO MATERIAL' EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 62 fL fL (�u/L
Monitoring Recovery ft. ft
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
_ 19.SAND/GRAVEL PACK(if applicable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. &
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets ifnecessary)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock tyM grain size,Me
G ft. fL
4.Date Well(s)Completed: �20ell ID# ft. ft. it
s1 'r
5a.Well Location: ft' Qu ft.
Persis-Nova Construction LLC ft. fa
Facility/Owner Name Facility ID#(if applicable) ft. ft.
15700 Youngblood Road, Charlofte, NC 28278 ft. &
Physical Address,City,and Zip ft. ft.
Mecklinburg 21.REMARKS County Parcel Identification No.(PIN) MAY
O 2 202?
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.
�G2 / l�rsflt � I
N W •— ''�
6.Is(are)the well(s)OPermanent or Temporary #Ignature of Certified ell 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 EC 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.
hued' 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 ifdifferent(example-3@200'and 2@I00) construction to the following:
10.Static water level below top of casing: Ce 00 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 1/4 (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
13a.Yield(gpm) Method of test: blow 24c.For Water SuDDIv&Iniection Wells: In addition to sending the form to
'n ,� the address(es) above, also subm one copy of this form within 30 days of
136.Disinfection type: HTH it Amount: 1 Ly,� 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 Watcr Resourecs Revised 2-22-2016