GW1--04398_Well Construction - GW1_20240723

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WELL CONSTRUCTION RECORD (GW-1 a� For Internal Use Only:
1.Well Contractor Information: . ) `
0(3'
.7rel u S Gk,u l[�li/ 14.WATER ZONES
Well Contractor Name FROM TO UF:SCRII'TION
ft. 1ft.
p2 15u, Ics ft. S e 34
NC Well Contractor Certification Number 15.OUTER CASING(for multi-canal,wells)OR LINER(if ap licable)
James Darby Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
O ft. 5 ft.-�'( /�in. St ye,it p,1 c
Company Name �+ V
2 w�G Q 16.INNER CASIN OR TUBING(geothermal closed-loop)
2.Well Construction Permit# `F Jv FROM TO DIAMETER THICKNESS MATERIAI.
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.
17.SCREEN
Water SupplyWell:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural D Municipal/Public 0 ft- ft. in. -
DGeothermal(Heating/Cooling Supply) xD Residential Water Supply(single) ft. ft. in.
Dlndustrial/Commercial D Residential Water Supply(shared) 18.GROUT
i Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: V ft- �G ft t7 `, j,• eQMi, (3 lot- S
0Monitoring D Recovery ft. ft.
Injection Well: ft. it.
DAquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
DAquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test DStormwater Drainage R. ft_
DExperimental Technology DSubsidence Control ft. ft.
DGeothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
DGeothermal(Heating/Cooling Return) [Other(explain under#21 Remarks)
Q ft. ft. C+ il
4.Date Well(s)Completed: Well ID# ft-'‘Co[ ft. sa
& .(.
Sa.Well Location: 5°6 ...5 qq� 11 v
ft. ft. Ji (.. •a
Michael Duarte jy-
Facility/Owner Name Facility BM(if applicable) ft. k
7908 Agape Ln. Waxhaw NC 28173 ft ft. _ JULr2 2024
Physical Addres,<_('th.and Zip ft. ft. ,
Union 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.Certification:tiQ
N W �S 4.-(7ZL6.Is(are)the well(s)�x Permanent or DTemporary Signsi.,
of Certified Well Contractor Date
By signing this form.1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or 3No with 1SA NCAC 02C.0100 or 1.14 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:
S.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: 0 (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 22@100') construction to the following:/
10.Static water level below top of casing: 11 1 (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 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 WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 6 Method of test: Blow 24c.For Water Supply& Injection 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 W CrL 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