GW1-2021-07855_Well Construction - GW1_20211102

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
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V. 14.WATER ZONES
o ' FROM TO DESCREMON
Well Contractor Name A '
r -i.':��{. ft ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a livable
James Darby Well Drilling LLC ,�: c,: :C)" FROM TO DIAMETER TMCIINMS MATERIAL
S+; ft ft �11 in. SM Ln �e
Company Name
�\/1/���O��� 16.INNER CASINGOR TUBING eothermal closed-loop)
2.Well Construction Permit#: V V FROM To DLAMETER TBICxivFss MATERw.
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 DiAMEi'ER SLOT SIZE THICKNESS MATERIAL
I Agricultural [)Municipal/Public Q fa ft. in.
Geothermal(Heating/Cooling Supply) xj Residential Water Supply(single) ft ft in.
i Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irri ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft C) fr 2 5
Monitoring DRecovery ft. ft
Injection Well: ft. ft.
_1 Aquifer Recharge D1 Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
1 Aquifer Storage and Recovery OSalinity Barrier FROM To I MATERtnt EMPLACEMENT METHOD
I Aquifer Test DStormwater Drainage ft &
Experimental Technology DSubsidence Control ft ft
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTTON color,hardness,soil/rock e, in size,etc.
Geothermal(Heating/Cooling Return) _) Other(explain under#21 Remarks) ft ft
,tr G
4.Date Well(s)Completed: V " 'Z1 Well ID# O ft /L ft 4
5a.Well Location: -2,5 ft ft
Jonathan Hibbard ft 25 ft I
'lity/O IJ Facility ID#(if applicable) ft ft
Catawba Falls P" , Old Fort NC ft ft.
Physical Address,City,and Zip ft ft
McDowell 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certification:
N W -ft
6.Is(are)the wells)OPermanent or OTemporary fpnalure ofCertifiedNVell 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: E]Yes or Xi No with 15A 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 921 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 tiurrace: 4 (ft-) 249. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdJfferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: n( (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 A (in.) 24b.For Injection 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) �O Method of test:blow 24c.For Water Supply&Iniec�tion Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
136.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