GW1-2021-00367_Well Construction - GW1_20210315

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
FROM TO I DESCRIPTION
Well Contractor Name
�1 8.5 ft. ft.
ft. I ft
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable
James Darby Well Drilling, LLC FROM TO DIAMETER THICKNEss MATERIAL
ft (� ft in. S���`� Ue
Company Name 13379
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.UIC,County,State,Variance,etc.) ff. ft. in.
3.Well Use(check well use): ft. ft. in.
17.
Water Supply Well: FROM SCREEN
TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ®MunicipaVPublic U ft ft. in.
1 Geothermal(Heating/Cooling Supply) XJ Residential Water Supply(single) g ft, in.
31 Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
_ J Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft ft
Monitoring J Recovery ft. ft.
Injection Well: ft. ft
1 Aquifer Recharge EI Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
i Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology 13Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
RGeothermal(Heating/Cooling Return) F30ther(explain under#21 Remarks) FROM TO DESCRIPTION color,//hardness,soil/rock tyM grain size,etc
ft. ft. AV
4.Date Well(s)Completed: _. 6 Well ID#
5a.Well Location: It 2 z ft.
William R Homes - ft ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. vr^h '+'' jam•'
1052 Lakefront Woods Dr. Belmont, NC 28012 ft ft. °
Physical Address,City,and Zip ft' ft' MAR �
Gaston 21.REMARKS
County Parcel Identification No.(PIN)
,vv
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certifrca' n:N W // //
F 3� —,2,,�
6.Is(are)the well(s)I Permanent or Temporary Sign a Certified Well Odntractor 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: Oyes or XJNo 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:
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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: nn SUBMITTAL INSTRUCTIONS
9.Total well depth below,land surface: 1/o� (ft•) 249. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(exam le-3@200'and 2@100')/- construction to the following:
10.Static water level below top of casing: 63 (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 A (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:
(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) ! 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: completion of well construction to the county he ent of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources * alth depRevised 2-22-2016