GW1-2022-04457_Well Construction - GW1_20220502

WELL CONSTRUCTION RECORD (GA-1) For Internal U
1.Well rontractor Information:
G I tce—z f(I 14.WATER ZONES
- FROM TO I DESCRIPTION
Well Contractor Name ft
3�2R�ZZ z%ft-
NC
Well Contractor Certification Number 15.Ov CASING for multi-cased wells OR LINER if ap licable
James Darby Well Drilling LLC FROM TO I DL-METER'+ THICKNESS MATERIAL
ft. ft- I in. - 1
Company Name 16.INNER CASING OR TUBING eothermal dosed-loop)
2.Well construction Permit#: 10012843 FROM TO DIAMETER THICKNESS MATERIAL
ft
List all applicable well construction permits(i.e.UIC,County.State, Variance,etc.) ft rn
ft ft in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DrAMETERi SLOT SIZE TNICKNESS MATERIAL
Agricultural E3Municipal/Public ft. ft in.,
Geothermal(Heating/COoling Supply) oC Residential Water Supply(single) ft. ft in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
-!Irrigation
ft ft
Non-Water Supply Well: �q�Ztlt• CJL��
Monitoring Recovery ft fL
Injection Well: ft. ft
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(if a licable.
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL LACEMENT METHOD
A uifer Test 0Stormwater Drainage ft. ft
EMP
q
-. Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if nee
FROM TO DESCRnPTION color.hardness,sotumck ryPe,gnin sire,etc)
RGeothermal(Heating/Cooling Rerun) nOther(explain under#21 Remarks) �J' ft ^ _-
_�
e9
4.Date Well(s)Completed: ell I�D# lr:�
5a.Well Location: qxs
ft ft P*
Persis-Nova Construction LLC
Facility/Owner Name Facility ED#(if applicable)
15700 Youngblood Road, Charlotte, NC 28278 ft `
Physical Address,City,and Zip
Mecklinburg 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Cc 'on(,
gnature of Certified ell Contractor Date
6.Is(are)the well(s)oPermanent or Temporary
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- OYes or EC No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
IJthis is a repair,fill out known well construction information and explain the nature ojthe
copy of this record has been provided to the well owner.
repair under 921 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 details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: C (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ijdii ferent(example-3@ 200'and 2@1001 construction to the following:
10.Static water level below top of casing: '`5 Cf (ft-) Division of Water Resotrces,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 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
L Method of test: blow 24c.For Water Supply&Iniection Wells: In addition to sending the form to
13a.Yield(gpm) the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: 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