GW1-2021-02364_Well Construction - GW1_20210527

L_
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: j
l'
FR WATER ZONES
Well Contractor Name T+_ FROM TO DESCR�TION
�`� A 11►fJ��`JG K ft. 3 p fr. f
ulJ2-/'� 3/z S/�il ' 1L ft. 1 M
NC Well Contractor Certification Number 15.OUTER CASING for multi-cas Is OR LINER if a licable
James Darby Well Drilling, LLC FROM TD DIAMETER THICKNESS MATERIAL.
Company Name — t ft. Q 1% (,,Iq in. Qg,_2,1 I �P O C.
10011833 16.INNER CASING OR TUBI G `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): It ft. in.
Water Supply Well: FROM E TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public ft. ft. in.
:)Geothermal(Heating/Cooling Supply) EiResidential Water Supply(single) ft. ft. iu.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
I Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: v ft. () ft. r
I Monitoring DJ Recovery ft. ft.
Injection Well:
ft. ft.
1 Aquifer Recharge []Groundwater Remediation
19.SAND/GRAVEL PACK if applivable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
I Aquifer Test E)Stormwater Drainage ft. ft.
I Experimental Technology OJ Subsidence Control ft. ft.
1 Geothermal(Closed Loop) E Tracer 20.DRILLING LOG attach additional sheets if necessary)
1 Geothermal(Heating/Cooling Return) E10ther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock gpe,grain sae,eta
0 It. t ft.
4.Date Well(s)Completed: Well ID# k
ft' ft. C
5a.Well Location: 12,9ft (oS ft. ;51 L'.
John Britt � ft rdo ft kroc
Facility/Owner Name Facility ID#(if applicable) ft. Igo ft. (I rock
10249 Saw Mill Rd. Charlotte, NC 28278 ft. ft.
Physical Address,City,and Zip ft. ft. t , CLI
Mecklenburg 21.REMARKS
21
County Parcel Identification No.(PIN)
IVIQY 2� I)nit
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I
ti.s ai;e,i c e
(ifwell field,one IatAong is sufficient) 22.Certification: D u Z SeCt;On
N W 5- I
XI
6.Is(are)the well(s) Permanent or Temporary Sign ur Cert d Well Contractor Date O
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 w 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 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: !mil) (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: (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use'+" 1617 Mail Service Center,Raleigh,NC 27699-1617
i6 1/4 ,
11.Borehole diameter: (n.) 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
(i.e.auger,rotary,cable,direct push,etc.) I
Division of Water Resources;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 20 Method of test:Blow 24c.For Water SuDDIv&InieeItion 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:�� �i� 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
i