GW1-2021-07903_Well Construction - GW1_20211102

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10129 12 Pririt'Form
WELL CONSTRUCTION RECORD(GW-I) For Internal Use Only:
1.Well Contractor Information:
WWATER,ZONES,
Well Contractor Name `,'1,l ";�..- DESCRIPTTION
NC Well Contractor Certification Number '";;, ulti-cased wells OR LINER'if a licable
James Darby Well Drilling LLC, ,,, j ,;�tt FROM R TO ft D1AMETERm THICKNESS MATERIAL
Company Name t',.
16.INNER CASING OR TUBING eotheirmal closed-loop)
2.Well Construction Permit#: V FROM TO DIAMETER THICKNESS MATERIAL
List all applicable trell construction permits(t.e.1/I(',Couniv„State.Varicntce,etc-.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) xResidential Water Supply(single) fr ft in,
Industrial/Commercial DResidential Water Supply(shared) 18;GROUT
I rrl ati on FROM TO MATERIAL EM LACEMENT METHOD&AMOUNT
Non-Water Supply Well: tt. ft.
Monitoring 13 Recovery
Injection Well:
rt. rt.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(ifopplicatile .
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/CoolingRetum) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soilhock e, rainsim,etc.)
ft. 16 ft.
4.Date Well(s)Completed: C) a1 'Z Well ID# I' ft. at ft. 1
ft.
5a.Well Location: ft.
Brian Dunn ft. IZv ft. 'Cwk A
Facility/Owner Name Facility ID#(ifapplicable) ft I Cb ft. w1 Wes/_ [I A�
6000 Stonepath Ln. Waxhaw, NC 28173 !� ft. LJ.l�ft. C �I'iT
Physical Address.City,and Zip ft. _19 ft.
Union 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.C'fleation:
C
N W dWO`-;--7 :11A
6.Is(are)the well(s)o Permanent or OTemporary iature ofCertified Well Contractor Date
Hv signing dtir/ornt, l herehv serif,that the well(s)tray(were)constructed in accordance
7.Is this a repair to an existing well: n Ves or E)No with 15A NCAC 02C.0100 or 15A N('AC 02C.0200 Well Consiruclion Standards and that a
1 f thi.v is a repair,_till out known well construction inlbrtna0on and explain the nature ql the copy of this record has been provided In the well owner.
repair under 121 remarks section or on the hack of 1his,/ornt.
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: / -! 11 A) 24a. For All Wells: Submit this form within 30 days of completion of well
hbr nndtip/e wells 1i.vt all depths ifdi/jereni(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,
lftrarer level isabove caving,ase"'" 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
roatary above,also submit one copy of this form within 30 days of completion of well
1 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) ID Method of test: blow 24c. For Water Supply& Iniection Wells: In addition to sending the form to
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the address(es) above, also submif one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: '601— completion of well construction to'dhe county health department of the county
where constructed.
Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016