GW1-2021-07856_Well Construction - GW1_20211102

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
Well Contractor Name c^"j FRO TO DESCRIPTION
��• `La ft 2 C, c- \
NC Well Contractor Certification Number \v,t f ,; t ft V,crct
Z
_t;r,•,. 15.OUTER CASING for multi-ca ells OR LINER if a livable
FROM [��
DIAMETER 1HICIflVESS MATERIAL
James Darby Well Drilling
Company Name ` v
16.INNER CASING OR TUDING(geothermal closed-loo
W21-0368
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft ft. tn.
3.Well Use(check well use): ft ft' in.
17.
Water Supply Well: FROM SCREENTO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural E)Municipal/Public U ft ft in.
Geothermal(Heating/Cooling Supply) x!Residential Water Supply(single) ft ft in.,
Industrial/Commercial 13Residential Water Supply(shared) 18.GROUT
1 1rri ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. Zv ft 2
Monitoring DRecovery ft ft
Injection Well:
ft ft
:)Aquifer Recharge nGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
:)Aquifer Test ElStormwater Drainage ft ft
Experimental Technology []Subsidence Control ft ft
Geothermal(Closed Loop) 1ITracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) _J Other(explain under#21 Remarks) FROM To DFSCLtIPTLON color,hardness soi0rock a is size
eta
�f ft. ft.f
4.Date Well(s)Completed: '` Well ID# ft ft
ft ft
5a.Well Ltio
Steoca
ve ca ft ft
Facility/Owner Name Facility ID#(ifapplicable) ft ft
2339 Catawba Falls Pkwy., Old Fort NC 28762 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:
(ifwell field,one lat(long is sufficient) 22.Certification:
N W (� AA,--r6UCk01
O�
6.Is(are)the well(s) xl permanent or OTemporary Si ture of Certified Well Contractor Date
By signing this form,/hereby cerr�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 02C.0200 Well Construction Standards and that a
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.
If
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 pagi to provide additional well site details or well
construction,only l 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: sbo (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@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 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
}� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: D oz. completion of well construction to the county health department of the county
where constructed. C
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016