GW1-2021-05442_Well Construction - GW1_20210527

WELL CONSTRUCTION RECORD GW- ` For Internal Use Only:
1.Well Contractor Information: 'Fox
t \ �S 7,' 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 1
3 \5� ft- \a�fr. ,o
fr. l q-7 tt.
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 THICKNESS MA�TyERIAL
Q ft. xk\ fr. �,1/q in. SD'L'� 1t V1__
Company Name
A 16.INNER CASING OR TUBING eothermal closed-loop)
2�_�
2.Well Construction Permit#: 4 FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) fL ft. in.
3.Well Use(check well use): fr. f`' in.
Water Supply Well: 17.SCREEN
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 13Municipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) IgResidential Water Supply(single) fr• ft. in.
_I Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irri ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: f fr' t�k- &WVV_i'P_
Monitoring ORecovery
Injection Well: fL ft.
)Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if a livable
I Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
I Aquifer Test [3Stormwater Drainage
I Experimental Technology OSubsidence Control fr. ft.
I Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soil rock in size,etc.
Geothermal(Heating/Cooling Return)
`Other(explain under#21 Remarks) 5--fr
4.Date Well(s)Completed: a ✓�` Well ID# a fit' IL 1—W\_ '507k
5a.Well Location: S� ft. $D fr. _15 n 15V —P w('1L
Mike Koman t` J t641u e-�fir- ,/
Facility/Owner Name Facility lD#(if applicable) 101 fr' a(, fr' 1 tor✓ 2 0 L 1�
5019 Lancaster Hwy. Monroe, NC 28112 .: ,A ,,..
Physical Address,City,and Zip ft. ft. may .
Union 21.REMARKS pp^
County Parcel Identification No.(PIN) Idl
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: r _„ a;� PrnoeSSlfi(g Unit
(if well field,one lat/long is sufficient) 22.Certification: [����Iq St`Y On
6.Is(are)the wells)(�lx Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,i hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or J No with iSA 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-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: U V (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100D 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:6 1/4 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Rota above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: Rotary 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:Blow 24c.For Water SuDDIv&Inie tion 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: HTH Amount: 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 Resou i s Revised 2-22-2016