GW1-2021-07801_Well Construction - GW1_20211102

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WELL CONSTRUCTION RECORD(GW-1) ,I '! v� For Internal Use Only:
I.Well Contractor Information: l
C` A, ` _ ` 4 1 .y�J
y\,cLr . +V tC/YW�J 9`�,r, I °�' 14.:WATER ZONES
Well Contractor Name TO DESCRIPTION
NC Well Contractor Certification Number -1 56f
t'") 15.OUTER CASING for multiien""wells ORtINER ifa t licable
James Darby Well Drilling LLC,`q�t�f� [)1� FROM it TO fL DI AM FT THICKNESS MATERIAL
Company Name >,.��`1 ,N in
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163850° 16.dNNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
5�
list all applicable (i.e.Ill(;('aunty,,Scale,V in.ariance,etc J ft. ft. .I� �
PyLl
3.Well Use(check well use): fr. ft. in,
Water Supply"'ell: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public 0 ft. ft,
NGeothermal(1-leating/Cooling Supply) x)Residential Water Supply(single) ft ft in.
Industrial/Commercial 0Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL�• EMPLACEMENT METHOD&AMOUN'I'
Non-Water Supply Well: ft. ft'
Monitoring DRecovery ft. ft.
Injection Well:
fr. ft.
Aquifer Recharge DGroundwater Remediation 19.SAND)GRAVEL PACK if a r licable
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft•
Experimental Technology Subsidence Control
:)Geothermal(Closed Loop) Tracer 20.'DRILLING LOG attach additidrud'sheets if necessary)
FROM TO DESCRIPTION(color,ha,dness,soil/rock tv e,,rain size,etc.l
Geothermal(Heating/Cooling Return) _ Other(explain under#21 Remarks) J
- 0 ft. 12,ft. a ,f'f0�.
4.Date Wells)Completed: Well ID# /;tl ft-ft. J 6 J ft. T Wax �vK-
_ 1`
Sa.Well Location: ' � 0�I _
ft. ft.
Facility/Owner Name Facility ID#(ifapplicable)
1110 Lake Montonia Rd kitgs iMa►la \.W fL
Physical Address,City,and Zip ft. it.
���d►td -2-WW 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Cer i Ication:`
N W f
6.Is(are)the well(s) x Permanent or QlTemporary Signature of Certified Well Contractor Dale
liy silming this form, 1 hereby cerilfy that the well(s)was(here)consaructed in accordance
7.Is this a repair to an existing well: n Ves or E]No with 15A NCAU 02C.0100 or 15A NCAC QU.0200 Well Conviruction Siandords and That o
1l'dii.s is a repair Jill out known a ell construction information and explain the nature q/7he copy q/this record has been provided to the irell corner.
repair ander 21 remarks.section or on the hack(?/'this irni.
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: I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 00 (ft-) 24a. For All Wells: Submit this_form within 30 days of completion of well
h'or t n itiple a e/A list all depths ijdi/)ereni(example-3@200'and 2 a7100') construction to the following:
10.Static water level below top of casing: 60 (ft.) Division of Water Resources,Information Processing Unit,
tf water 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,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 Supply& Infection Wells: In addition to sending the form to
/U_, / 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.
I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016