GW1-2021-02318_Well Construction - GW1_20210527

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
WATER ZONES DESCRIPTION
Well Contractor Ng6e /
ft.
21A ft 240 ft M
NC Well Contractor Certification Number 15.OUTER CASING for multi wells OR LINER if a livable
James Darby Well Drilling LLC FROM TO DIAMETER Eh
MATERIAL
Company Name 4�4( ft (o ( ; in. 11cA21 '��
13328 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,Stale,Variance,etc.) ft• ft. in.
3.Well Use(check well use): ft. fL in.
17.
Water Supply Well: FROME TO DIAMETER SLOT SIZE THICKNESS MATERIAL
_ Agricultural IDMunicipaYPublic 0 ft. ft.
Geothermal(Heating/Cooling Supply) x Residential Water Supply(single) ft. ft. in;
Industrial/Commercial OResidential Water Supply(shared) I&GROUT
Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: IL IZ6 ". 4.41 Po-u✓ M 5
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
I Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
_1 Aquifer Test CJ Stormwater Drainage ft. ft.
I Experimental Technology Subsidence Control ft. ft.
t Geothermal(Closed Loop) OTracer 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 type,grain size,etc
0 fa (O ft• C
4.Date Well(s)Completed: 4413-21 Well lD# 433 2po co fL O ft. e(�
5a.Well Location: O ft O ft G�4
Andy Lutz Construction W ft G fL S Ib(Y b•�.rn
Facility/Owner Name Facility ID#(if applicable) w ft. 4o ft -r /t
114 Olde Philadelphia Way, Dallas, NC 28034 I-,o ft. 2to ft. S�F�
Physical Address,City,and Zip ft.
Gaston 21.REMARKS 1
County Parcel Identification No.(PIN)
ow
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certification
6.Is(are)the well(s) o Permanent or OTemporary Signature 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: Oyes or IgNo 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 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: (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths 1f different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: (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) 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 formwithin 30 days of
13b.Disinfection type: hth Amount: 00 M 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 I Revised 2-22-2016
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