GW1-2021-04022_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD (GW-1)�^ For Internal Use Only:
1.Wellll Contractor Information: ►�v�
Q'y\to-`,C. 1 7A I 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
ft. ft. 1
NC Well Contractor Certification Number 15.OUTER CASING for multi-caseil Hells OR LINER if a licable
James Darby Well Drilling, LLC FROM TO DIAMETER THICKNESS MATERIAL
p ft. a'1 ft. G yN in. p�
Company Name
21-223 16.INNER CASING OR TUBING "cothermal closed-loop)
2.Well CODStrUC110D Permit#: FROM TO DIAMETER THICKNESS MATERIAL
Lit all applicahle well eottvruction permits(i.e.IIIC,c ounil:.Steve. 12iriance,etc) rr. rc. in.
3.Well Use(check well use):
17,SCREEN
Water Su I'Well:pp} FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural Municipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) IS.GROUT
Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. 1 Q e
Monitoring EIRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) E)Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) 'Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness,soil/rock type, rain sae,cu.)
I ft. fr.
4.Date Well(s)Completed: I a` Well ID# ft. 4 R. jQ - �.� Ex WL
Sa.Well Location:
Joshua Starnes
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. -�
6823 Lancaster Hwy. Waxhaw, NC 28173
Phvsical Address,City,and Zip ft. ft.
Union 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certification:
N W 7 - J- 2k
6.Is(are)the well(s)o Permanent or OTemporary SS iature of Certified Well Contractor Date
Iuv signing this/orw, l herehl cerh/i,that the we//(v) wa.v(were)construc•led in accordance
7.Is this a repair to an existing well: Dves or HIND with/5A NCAC 02C.0100 or 15A N01('02C.0200 Well Construction,Slandardv and/licit it
1/this is a repair.fill aut known well construction hilbrina/ion and explain the na/tn•e uJ the copy n/this record has been Provided to the well owner.
repair under 2/remarks section or on the hack n/7his./hnn.
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 I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: — , SUBMITTAL INSTRUCTION
9.Total well depth below land surface: 5 OO 24a. For All Wells: Submit this form within 30 days of completion of well
l•or multiple welly list all depths it ebljereni(e.rainple-3 a 200'and 2L�i@100') COnStruC[IOIt l0 tI7C following:
10.Static water level below top of casing: I7 (ft.) Division of Water Resources,Information Processing Unit,
l/water level is above casing;.use" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 1/4 (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,) Inderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) tAri Nlethod of test: Blow 24c. For Water Supply & Infection Wells: In addition to sending the fonn to
Q the address(es) above. also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: 1%aL completion of well construction to the county health department of the county
where constructed.
Fonn GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016