GW1-2021-00528_Well Construction - GW1_20210315

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ELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
it. I tt.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINE&tf a livable
James Darby Well Drilling, LLC FROM i) DIAMETER THICKNESS MATERIAL
Company Name D ft l l O r t �v?/ in. ,��R„�I I /'vd
320915 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,State,Variance,etc.) fL ft. in.
3.Well Use(check well use): ft. ft in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public ft in. u
lg' !xa -tea �Ue
Geothermal(Heating/Cooling Supply) E Residential Water Supply(single) ft. ft. in.
Industrial/Commercial [)Residential Water Supply(shared) 18.GROUT
711rrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft D Aoyd
Monitoring 13Recovery ft. fL
Injection Well:
ft. ft.
Aquifer Recharge QGroundwater Remediation
19.SAND/GRAVEL PACK tf a livable
Aquifer Storage and Recovery OSalinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
I Aquifer Test [3Stormwater Drainage ft.
Experimental Technology [3 Subsidence Control ft.
i Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
I Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock tyM grain ske,etc
© ft. S" ft. Re /
4.Date Well(s)Completed:1 aaWell ID# ft. ft. Ito on C�/F
5a.Well Location: O ft• .f ft ,?c u/n. s14nd )--Lk
Jay Hosack qS ft 1 >2 e d del V
Facility/Owner Name Facility ID#(if applicable) ft. fL n.
"'
112 Kiowa Ct. China Grove, NC 28023 fL ft. `' '%n_r,p-`R-
Physical Address,City,and Zip ft. ft t M
Rowan 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if we0 field,one latllong is sufficient) 22.Ce 'on- 7 N W ec -�
6.Is(are)the well(s)JI Permanent or []Temporary Sigilatureof Certified W 1 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: ®Yes or XI No 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 thisform.
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:���t`9 (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:
10.Static water level below top of casing: 25 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,rise"+„ 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) 30 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: Y D 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