GW1-2022-03121_Well Construction - GW1_20220307

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
�L(!. S t�2�12 14.WATER ZONES is
Well Contractor Name FROM TO DESCRIPTION
jy ft. R v ft. S ►I 1 4"d-,"- 'r' ►+,
517 fr. 1 R ft- 4-as-e-K) q5'+ P ,
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a p livable
James Darby Well Drilling LLC FROM TO DIAMETER THICKNESS MA®TERIAL
Ut ft. 5 /ift. L I in. s�(L^'d1
Company Name / - 1 -.
E H W2�—0242 1 16:7NNER CASING ORTUBING cothei•mal closed-too
2.Well Construction Permit#' FROM TO DIAMETER THICKNESS MATERIAL
List all applicable ire/l construction permits(i.e.Ill('.r ounlY,State,Variance.etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
IT.
Water Supply Well: '-SCREEN'
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public 0 ft. fr. in.
Geothermal(Heating/Cooling Supply) EJResidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. ft. Ale P'o OWIL
Monitoring Recovery
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19,SAND/GRAVEL PACK(if applicable)
I. "
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
Aquifer Test oStormwater Drainage
Experimental Technology OSubsidence Control ft. ft.
Geothenmal(Closed Loop) Tracer 30.DRILLING LOG'attach additional sheets if necessary)
_ FROM TO DESCRIPTION(color,hardness,soilimck tv e. min size,etc.)
'Geothermal(Heating/Cooling Return) Other(explain under Remarks)
�1 p rt. rL ReZ CI ,a w vu I etc
4.Date Well(s)Completed: Well ID# ft. ft.
ft. fr.
5a.Well Location: W>rr own C
Doug McCurry L114f' 7 k
Facility/Owner Name Facility ID#(if applicable) q7
ft. r1 ft. /10 Q
Lot# 38 Sigmon Farms Iron Station NC ft• ft t
Physical Address.City,and Zip ft. ft.
Lincoln 21.REMARKS
County Parcel Identification No.(PIN)
r- Q---
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.Cel to ttion:N W (Z)ke 6� /0—G—.242/
6.Is(are)the well(s) Permanent or OTemporary Signature of Certified Contractor Date
Bi,signing this Jornh, I herehv cerltfj,that'the rrell(s)was(here)Constructed in accordance
7.Is this a repair to an existing well: nYes or E)No with 15A NCAC 02C.0100 or 15A NCAC h2C.0200 Well Construction Standards and than a
4 this is a repair.Jill out known hrel/construction information and explain the nature q/"the copy of This record has been provided to the wet/corner.
repair under 11 remarks section or on the back o/'Ilus itbrm.
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 I 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: S 2-3 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
I•'or mnhiple hre/Ls list all depths ifdi#)rent(example-M.D200'and 2@/00') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
I/ualer level is above cacinl;,use' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 1 A (in.) 24b. For Infection Wells: In addition to sending the form to the address in 24a
rotary above,also submit one copy of this forn 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 lonTl to
the address(es) above, also submit ',one copy of this form within 30 days of
13b.Disinfection type. HTH Amount: •Z 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