GW1-2021-03654_Well Construction - GW1_20210823

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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
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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