GW1-2021-00365_Well Construction - GW1_20210315

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
A rL„1 �� Ze-ez. 14.WATER ZONES
Well Contractor Name 1 FROM TO DESCRIIMONft-
/
3110 A I ft. It.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if applicable)
James Darby Well Drilling, LLC FROM TO DIAMETER TWC.NESS MATERIAL
O ft. % ft. I ( L in.
Company Name 13380 to
16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.WC,County,State,Variance,etc.) ft ft 1O
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROMREE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ®MunicipaVPublic 0 ft. ft. in.
Geothermal(Heating/cooling Supply) xl 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: It p I )0
31,Monitoring DRecovery ft. fL
Injection Well: fL ft•
1 Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK ifa livable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
3Aquifer Test []Stormwater Drainage ft ft
Experimental Technology OSubsidence Control ft• ft
1 Geothermal(Closed Loop) 13Tracer 20.DRILLING LOG attach additional sheets if necessary)
I Geothermal(Heating/Cooling Return) __,) Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness soiUrock in sire etc.
ft. ft
)Other
Date Well(s)Completed: —;2 S /Well ID# ft' ft' G/ Rae C
5a.Well Location: ft 2 -'- f S C!'
William R Homes It ft. lvtl .-
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1042 Lakefront Woods Dr. Belmont, NC 28012 ft. B.
P�
Physical Address,City,and Zip ft. ft.
Gaston 21.REMARKSMAR
County Parcel Identification No.(PIN)
I�1fornl34iefl Prar-el-slr1, 1 '
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: "' ,,,`,
(if well field,one lat/long is sufficient) 22.Certification:
N W
6.Is(are)the well(s) Permanent or Temporary S t'i,re of Certifie e 1 ontr
xl 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: []Yes or JqNo 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: �2_ytx (ft.) 24s. 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: rl. (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 1 A (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
13a.Yield(gpm) d Method of test:Blow 24c.For Water Supply&Infection 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 922 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