GW1-2021-07852_Well Construction - GW1_20211102

� Print-Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
r � 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Nam s �/� fL
n�i, ft . ft. l rK
NC Well Contractor Certification Number 15.OUTER CASING for multi-cas ells OR LINER if ap licable
James Darby Well Drilling LLC FROM I To DIAMETER TEICIINESS MATERIAL
O IL c) ft. Co in-
n 2 V VC
Company Name �
W21-0364 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER TtrlCl-- MATERrar.
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
PP Y FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL.
:]Agricultural DMunicipal/Public U ft. ft. in.
Geothermal(Heating/Cooling Supply) IgResidential Water Supply(single) fL ft. in.,
Industrial/Commercial [Residential Water Supply(shared) ls.GROUT
I Irrigation FROM TO I MATERIAL EMPLACEMENT MEI71101)&AMOUNT
Non-Water Supply Well: C) ft. <0 ft t o
I Monitoring OJ Recovery ft. ft.
Injection Well: ft. ft.
1 Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
1 Aquifer Storage and Recovery I3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METIOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology C Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soillrock in size,etc
Geothermal(Heating/Cooling Return) J Other(explain under#21 Remarks) & fL
4.Date Well(s)Completed: / Well ID# ft. ft.
ft. ft.
5a.Well Location:
Jonathan Hibbard ft. ft.
Facility/Owner Name Facility 1D#(if applicable) ft. ft yr-
265 Feather Falls, Old Fort NC 28762 ft. ft.
Physical Address,City,and Zip ft. ft ry•nf-: . ':'^1:i3 McDowell 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.Certification:
N W J�� _
6.Is(are)the well(s) XI permanent or Temporary Si tore of Certified Well Contractor Date
By signing this form,1 hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or 19No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
lfthis 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'
9.Total well depth below land surface: 22� (fL) 249. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths i,(different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 00 Division of Water Resources,Information Processing Unit,
lfwater 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,jUnderground 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
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 Resources Revised 2-22-2016