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HomeMy WebLinkAboutGW1-2021-03654_Well Construction - GW1_20210823 I^---ri'i n rravrrn—^^ WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: 1.Well Contractor Information: ` I 14.WATER ZONES Well Contractor Name FROM TO DESCRIPTION 315T a-� ass fL g�IS�21 ft. � NC Well Contractor Certification Number ft.15.OUTER CASING for multi cased wells OR LINER if a livable James Darby Well Drilling LLC FROM To DIAMETER THICIINESS MATERIAL. Company Name ���� 0 ft. 0 ft. �i�tj in. f(2 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) ft• ft. in. 3.Well Use(check well use): ft, ft. in. Water Supply Well: 17.SCREEN I1tOM TO DIAMETER SLAT SIZE THICKNESS MATE UL I Agricultural 13Municipal/Public ft. ft in. Geothermal(Heating/Cooling Supply) x!Residential Water Supply(single) ft g, in. Industrial/Commercial D1 Residential Water Supply(shared) 18.GROUT Irrigation FROM_ TO MATERIAL EMPLACEMENT METHOD&AMOUNT Non-Water Supply Well: fL 'Lo fL (q— Monitoring Recovery ft. ft. Injection Well: ft. ft. Aquifer Recharge DJ Groundwater Remediation 19.SAND/GRAVEL PACK if applicable) _1 Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD Aquifer Test �Stormwater Drainage ft. ft. Experimental Technology 13Subsidence Control Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary) 1 Geothermal(Heating/Cooling Return) _ Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiVrock in size,etc K ft ft. 4.Date Well(s)Completed: J 'ZS �1 Well ID11 (1 k ft' (r° 5a.Well Location: Sls 1 Deborah Lee G ft. fft %o► 1 Facility/Owner Name Facility ID#(if applicable) 'vft' b w"ep 308 Forest Bay Ct. Belmont, NC 29012 .I,7 Srt• Sob ft' c-- Physical Address,City,and Zip ft. ft' Gaston 21.REMARKS County Parcel Identification No.(PIN) 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (if well field,one Iat/long is sufficient) 22.Ce '[cation N W 6.Is(are)the well(s) XI 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: MYes 'or Xi 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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also;attach additional pages if necessary. drilled: SUBMITTAL INSTRUCTIONS t 9.Total well depth below land surface: �d (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@1001 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 It.Borehole diameter: 1� (in.) 24b.For Infection 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: t t TkDyeN 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) 0 Method of test: 24 For Water Supply&Infection Wells: In addition to sending the form to ,1 'I the address(es) above, also submit,one copy of this form within 30 days of 13b.Disinfection type: ^ Amount: `f(!L completion of well construction to the county health department of the county where constructed. Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016