GW1-2021-00657_Well Construction - GW1_20211222

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: C
�.J 14.WATER ZONES
zy
FROM I TO I DESCRIPTION
Well Contractor Name
ft. � ft.
1 , ft
NC Well Contractor Certification Number 5. TER CASING for multi-cased wells OR LINER if a licable
James Darby Well Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
Company Name ft- 13D ft. I &yN m.
I � 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO I DIAMETER THICKNESS MATERLII
List all applicable well construction permits r.e.UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
SCREEN17.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
11 Agricultural DMunicipal/Public 0 ft. ft. in.
i Geothermal(Heating/Cooling Supply) xI Residential Water Supply(single) ft, g,
I Industrial/Commercial DJ Residential Water Supply(shared) 18.GROUT
Itri ation FROM I TO MATERAAI. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft ft' �je`'9dlv�e
i Monitoring DRecovery ft. %
Injection Well:
It. ft.
I Aquifer Recharge []Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
I Aquifer Storage and Recovery Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
I Aquifer Test DStormwater Drainage ft. ft
I Experimental Technology Subsidence Control ft ft.
Geothermal(Closed Loop) []Tracer 20.DRILLING LOG attach additional sheets if necessary)
I Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soNrock type,gnin size,etc
fL /D ft
4.Date Well(s)Completed: Well ID# ft. ft. , C
5a.Well Location:
New Traditions Homes ft /20 fr. er/ fl�
Facility/Owner Name Facility ID#(if applicable) /1._10 ft. ft pi0
Lot 6 Arrow Plantation, Waxhaw NC 28173 ft. ft' F
Physical Address,City,and Zip ft. ft. DEC 2 2 2021,
Union 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.Ce cation:
e—
N W
6.Is(are)the well(s)ox Permanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby cenify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or JDNo 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#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
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9.Total well depth below land surface: o (ft.) 249. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3 a200'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
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II.Borehole diameter: �8 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
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: J 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 9-o Method of test•&7Lt/ 24c.For Water Supply&Inied us,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: Amount: A0,071 completion of well construction to 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
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