GW1--05282_Well Construction - GW1_20230814

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: y 1
544 4 l e1 Kt S��Z{� 14.WATER ZONES / O -'"x'C.J.'b t y liar
Well Contractor Name / /28
FROM TO DESCRH•I'ION
a 1, �.� 17/D. 3 IS' ft. a 14 ft. •vk :1159 P"4
•
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(i ap licable)
. James Darby Well Drilling, LLC FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. I 616 ft. L. in. FD Q-2( Jo e_
10013535 16.INNER CASING OR TUBING(geothermal 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): R. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural fMunicipal/Public 0 ft• ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
-Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: V ft. Or tam ft. 4d/e Pt v5 pc u et
Monitoring IDRecovery ft. ft. r
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery .Ql Salinity Barrier FROM TO . MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) b ft ft. pi/ grs),tiod-
4.Date Well(s)Completed: 6- lY'.1 3 Well ID# G ft' g ft' /ze...i. LD
5a.Well Location: e'i ft. ,DO r ft. p�
d ► sa4:1
Daniel Daywalt 106 ft. 2 5l0 ft. S*vi4.•
Facility/Owner Name Facility ID#(if applicable) a I/O ft' .3 y3ft. a-1`/
7 {� 14.4.h J
1821 Rockabill Rd ft. ft. r.-,77._r,_.,
Physical Address,
ess.City and Zip+�(' ft. ft. N \L..y..i 4...i V L.L.'
Charlotte I 'e.c0f Y1buR 21.REMARKS AUG Y .1 LUZJ
County L Parcel Identification No.(PIN)
ir. ;,r.:4 n?rn.��=..::',9 Unit
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: LN1 3 .-1+a
(if well field,one lat/long is sufficient) 22.Certifi lion: / /
N W (D�T c2023
J ]
6.Is(are)the wells)JPermanent or j jTemporary Signet of Certified Well on[ractor Date
By signing this form,I hereby cert fy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or lNo 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: 2 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 7 y 3 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100')) construction to the following:
10.Static water level below top of casing: 0 2- (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 1/4 (in.) 24b.For InjectionWells: 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) l 17 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: 7 b 7.- 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