GW1--06458_Well Construction - GW1_20231002

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Ckk la 4e___ 1 Ot al5 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name /
ry/z ./� �
� �QI ft. 211._ft. ti 7/1,
NC Well Contractor Certification Number Vl 15..OUTER CASING(for multi-cased wells)
wells)OR LINER(if ap licable)
James Darby Well Drilling, LLC FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. '3 2ft. / ,/q ' in. N�.)...l P fr-`
10013824 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,Stale,Variance,etc.) ft. ft. in.
3.Well Use(check well use): it. ft. in.
1Water Supply Well: FF7R SCREE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) D Residential Water Supply(single) ft. ft. in. '
Industrial/Commercial D Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: D ft. �w ft � 1 l_
Monitoring Recovery ft. !U ft. ''fii ,
�'ft
Injection Well: --
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery D Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology D Subsidence Control ft. ft.
Geothermal(Closed Loop) ©ITracer 20.DRILLING LOG(attach additional sheets if necessary)
_ FROM TO DESCRIPTION(color,hardness,soiUrock type,grain size,etc.)
Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) 0 ft. / . ft. fRed
4.Date Well(s)Completed:(P.23r Well ID# to ft. 37,e ft. •r6-• r.�t 7
.5a.Well Location: ft. (99,
ft.
TitM�. 5 e
Sabrina Coulston (yis ft. /74 . T3,,v,,,`0 .1'4411 love
Facility/Owner Name Facility ID#(if applicable) ,^y1ft. Nat ft. 1.
6718 Timahoe Ln Charlotte, NC 28278 WeI( ft. ft. �i�
Physical Address,City,and Zip ft. ft.
Mecklenburg ` ' 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Q r T C 2 21j(�
23
(if well field,one lat/long is sufficient) 22.Certifica'on:
. ,. -3,-,,,,--- 'a yn.?.1:
I I✓i' E.v:i :7
6.Is(are)the well(s) Permanent or JTemporary Signature of Certified Well 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: J)Yes or jNo 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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: YD (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:
f
10.Static water level below top of casing: D 3 (ft.) Division of Water Resturces,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: il
(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) V Method of test: Blow 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also subunit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: completion completion of well construction to the county health department of the county
where constructed. i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016