GW1-2021-04021_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
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C I,0 r k 1 t, �).i 14.WATER ZONES
Well Contractor Name FROM TO DESC EM
a (t� 00 fL ON
ft. fL
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a livable
James Darby Well Drilling, LLC FROM To DIAMETER'n THICIavEss MATER�
Lo fL y�ft. ` S1721-1 I/v
Company Name
20-459 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO D
2.Well Construction Permit#: IAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC,County,State,Variance,etc) fL fL in.
3.Well Use(check well use): ft. % in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
]Agricultural OJ Municipal/Public U ft. fL in.
l Geothermal(Heating/Cooling Supply) E Residential Water Supply(single) ft, ft. in,
J Industrial/Commercial (Residential Water Supply(shared) I&GROUT
__j Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft90ft k, 7F+�
D1 Monitoring 13Recovery ft. ft.
Injection Well:
ft. ft.3_1 Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
1 Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. fL
I Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRU TtON color,hardness,soillrock in ske,etc.
__Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) fL r ft.
4.Date Wells)Completed: Well ID# ��_ft ',��ft. ^^(� O 1 L
5a.Well Location: ft. G
Ali Alipour fL
Facility/Owner Name Facility ID#(if applicable) ft. ft
12532 Pine Valley Club Dr. Charlotte, NC 28277 fL ft
Physical Address,City,and Zip ft' ft t(! L
wo
Union 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W
6.Is(are)the well(s)olx Permanent or OTemporary Signature of Certified ell 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: [3Yes or Jallo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fell 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: I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) 249. 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
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,k Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) O Method of test:Blow 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also subrhit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: I U 6L- completion of well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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