GW1-2021-03752_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
i
e���1 14.WATER ZONES
c. FROM TO DESCRIPTION
Well Contractor Name
u ft ft ft. ft.
/>(J fic ell9 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 D TER THI"IN MpATERIAL.
fL & in.
Company Name 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.) R ft. In.
3.Well Use(check well use): ft. & in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLAT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public 0 ft. ft. in.
I Geothermal(Heating/Cooling Supply) _ gle) ft. ft. io
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
LTi ation FROM I TO MATERIAL / EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: IN, ft ft
I Monitoring QRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge ©I Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
1 Aquifer Storage and Recovery DSafinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
I Aquifer Test OJ Stormwater Drainage ft. ft.
I Experimental Technology Oj Subsidence Control ft. ft.
I Geothermal(Closed Loop) LPTracer 20.DRILLING LOG attach additional sheets if necessary)
1 Geothermal(Heating/Cooling Return) f3Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock tym grain size,etc
It. Is' ft.
4.Date Well(s)Completed. ��� �GWell ID# ft L 8 ft' `iLo'Jai
5a.Well Location:
Tripp White ' ') ft. -Ov 1t.
ft. fL
Facility/Owner Name Facility ID#(if applicable) a
4498 Reepsville Road, Vale NC 28168 ft. fL
Physical Address,City,and Zip It. ft.
Lincoln 21.REMARKS
n
4, .'
County Parcel Identification No.(PIN)
'�
r r�` .1v�.i•'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: C'
/�,, 4,1, -
6.Is(are)the well(s) xI Permanent or OTemporary Sigr&ure of Certified Well,Contractor- ' __1 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: Q]Yes or XI No with 15A NCAC 02C.0100 or 15A NCAC 01C.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: R 6 0 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 1@100) construction to the following:
10.Static water level below top of casing: (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: (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
�, above, also submit one copy of this form within 30 days of completion of well
12.Well construction method:� /� �/7 r.` '� 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: (l5 'Q 14.1 24c.For Water SuvvIv&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: Amount: t D-z- 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