GW1--06217_Well Construction - GW1_20230925

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
7aS PI) 8grie0 i
14.WATER ZONES.. t 1=y, ;,:
Well Contract r Name FROM TO DESCRIPTION
32�� q�l$ •
11° n igo2 ft. ,fyJi //icria. 20`i '
NC WellContractor Certification Number / /� ✓ t �& f �m`f�� r "'IGr"/i' Bwl
15.OUTER CASING(for multi-eased wells)OR LINER(if ap licable) ,:
James Darby Well Drilling LLC FROM TO DIAMETER THICKNESS 1 MATERIAL
a ft. /agift. 4 asin. S,oR a I Ai
Company Name ^/ . 16.INNER CASING OR TUBING(geothermal closed-loop) ' `�^ ' •
2.Well Construction Permit#: j^/� R�� 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 ft. ,, in.
Water Supply Well: 17.SCREEN• :;;
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural IDMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) N1Residential Water Supply(single) ft. ft in. ,
Industrial/Commercial DResidential Water Supply(shared) 18.GROU 1
Irrigation- FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: G It. t7 p ft /3ewI nii / lv c slf,
Monitoring DRecovery ft ft.
Injection Well:
ft. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable) - ,,,•'..` ' , -+' ,-
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Ell Stormwater Drainage ft. ft.
Experimental Technology I0Subsidence Control ft. ft. 1.
Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if necessary) .. '
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ft. �}O ft e� s6�//
4.Date Well(s)Completed: Well ID# ft G0 ft. /3ra /7 Sao $T I /
p V (((JJJ
5a.Well Location: 40 ft- /o 0 ft. {//al✓le [h^� soli
4dçf
Dan Reader l ovS'G /00 ft / /f)ft /reVEnii./(1 S4nd..orl Facility/OwnerName FacilitylD#(ifapplicable) /v ft. , a0 /-_ ii / BG/<
6635 Old Settlers Road,Waxhaw NC 28173 f (r���
/�v ft. 3 0� ft jar RQ6/c
Physical Address,City,and Zip ft. ft.
Union OJT•69/o-009._ `21 REMARKS .. - ,, k _, C`i< , , :
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: S E P 2 2023
(if well field,one lat/long is sufficient) 22.Certifi rt n: / 1 1
j`1 wFte�slSil ',^^, Q99vT' lJ .3
N W r DtF COlha ( d a d...___
.
6.Is(are)the wellXs) Permanent or Temporary Sra,a.."ofC� red Well Contra 1 Dat
By signing this form,.I hereby ce <.%'that the well(s)was(were)constructed in accordance
, 7.Is this a repair to an existing well: fYes or INo ith 1SA NCAC 02C.0100 or 15 CAC 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: SUBMITTAL INSTRUCTIONS
l
9.Total well depth below land surface: 3oa VI) 24a. For All Wells: Submit tliis 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: 1
10.Static water level below top of casing: 3(( (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: 61/4 (in.) 24b.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 WELLSlny ONLY: 1636 Mail Service;C inter,Raleigh,NC 27699-1636
13a.Yield(gpm) f CT/"iil Method of test: blow 24c,For Water Supply&Iniection Wells: In addition to sending the form to
the addresses) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Hill Amount: completion of well construction Ito the county health department of the county
where constructed. I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources s 1 Revised 2-22-2016