GW1-2021-07854_Well Construction - GW1_20211102

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WELL CONSTRUCTION RECORD(GW-1) ,,a For Intemal Use Only:
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1.Well Contractor Information: ""5
21 14.WATER ZONES
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FROM TO DESCRIPTION
Well jpmrniztor Name f.
,c" ft.:1 I lVft. ,� �
NC Well Contractor Certification Number t'' ty �" Y/
�.`•"' \j�;'�`�� 15.OUTER CASING for multi-cased e s OR LINE ifs icab
James Darby Well Drilling LLC FROM To DIAMETER 1HICIINFSS MATERIAL
Company Name ft ft r^ in Z a U C
1 p/� ®�/f2�J 16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit V V 1 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.
17.SCREEN
Water Supply Well:
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
I Agricultural DMunicipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) Xi Residential Water Supply(single) ft. ft, in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
I Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q It. 2O ft
I Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
1 Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
1 Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E)Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. It.
RGeothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) J Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiVroek a in sae etc
Q ft C ftcl
4.Date Well(s)Completed: fl^ 2- Well ID# ft ft ACdl
5a.Well Location: Zak ft
Jonathan Hibbard ft. f`
F �#Name Facility ID#(if applicable) ft ft-
Catawba Falls P"., Old Fort NC 28762 ft. ft.
Physical Address,City,and Zip It. ft.
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 0 b 2-
6.Is(are)the well(s) xl Permanent or ❑Temporary Si ve o'Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or Xi No with 15A NCAC 02C.0100 or 15A NCAC 01C.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
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9.Total well depth below land surface: -ZO 00 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@100') 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
11.Borehole diameter:6 1/4 (in.) 24b.For Iniection 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&Injecion 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 io 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