GW1-2021-02339_Well Construction - GW1_20210527

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
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14.WATER ZONES
Well Contractor Name ^ FROM TO DESCRIPTION
S, F.,,�o„Q ft. ft _fie t
IZ4 ft ft I
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable
James Darby Well Drilling LLC FROM To DIAMETERI THICKNESS MATERIAL
Company Name
6 ft ft in. ( &e 1 r
E H W21'00032 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.) ft ft. in.
3.Well Use(check well use): ft• ft in.
Water Supply Well: FR M REE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
J Agricultural ©Municipal/Public ft 111 fL in.
Geothermal(Heating/Cooling Supply) []Residential Water Supply(single) ft ft. I in.
: Industrial/Commercial xi Residential Water Supply(shared) 18.GROUT
I Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 & .2 j ft. d va
Monitoring ®Recovery ft. ft.
Injection Well:
ft. ft. '
_1 Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK if applicable
I Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
J Aquifer Test OJ Stormwater Drainage ft. ft
I Experimental Technology Subsidence Control ft. ft
I Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks)] FROM TO DESCRIPTION color,hardness,soWrock type,grain size,eta
ft. ft.
4.Date Well(s)Completed: =2galWell ID# ft. ft �Loti n 1h
5a.Well Location: zia
ft ft• �I� a u� �0t
Chris Connor ft, qz
ft. �riecl Roe 1�
Facility/Owner Name Facility ID#(if applicable) & ft. AID �� _ �; O 3�S'
7127 Lackey Road, Vale NC 28168 It ft.
Physical Address,City,and Zip ft. ft.
Lincoln 100949 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ;
n�o�glll�1.1tSit
(if well field,one lat/long is sufficient) 22.Certif lion u Zrt10I►
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N W -6•02���
6.Is(are)the well(s)oPermanent or OTemporary Si ae Certified We ntractor 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 X�No with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 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 I 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: 7/)a (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: i
10.Static water level below top of casing: (ft.) Division of Water Reso f rces,Information Processing Unit,
If water level is above casing,use"+" � 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
f� above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: U 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
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13a.Yield(gpm) Method of test: ` 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit lone copy of this form within 30 days of
13b.Disinfection type: Amount 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
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