GW1-2022-04298_Well Construction - GW1_20220502

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
r 14.WATER ZONES
Well Contractor Name T_ _ FROM TO DESCRIPTION
.�y r-�xj r� fLa ft.
3 2 7L 4 y-/a { /Z—Z �Ro ft, fL 6
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER tf a licab e
James Darby Well Drilling LLC FROM TO DIAMETER ' THICKNESS MATERIAL
/� ft ft. in.
Company Name �-/
16.INNER CASING OR TUBING eothermal dosed-loop)
2.Well Construction Permit#: C)i" i S 5 y 3 D FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(r.e.WC,Coung'.State, Variance,etc.) ft ft in.
3.Well Use(check well use): ft fL in.
Water Supply Well: 17.SCREEN
_ FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [JMtmicipal/Public ft, ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared)
18.GROUT
lIrrigation FROM TO MATERIAL EM LACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0
IL
ft
Monitoring Recovery ft ft
Injection Well:
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test [)Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) [3Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock e, rain size,etc.)
% J d ftRal so,,
4.Date Well(s)Completed Well ID# ft. ft. a
ft ft. /O
Sa.Well Location:�j
IV[P_" ���%h;.A j Q::i G ft ft
Facility/Owner Name Facility ID#(if applicable) ft. tt
J 6 5 Is, , /�Ll�J_& Y u' �,/.C n ft
� �CIrLC �'ri �, t
Physical Address,City,and Zip � ft
7JO1Ilie2IO 21.REMARKS` h a �w. .
r
County Parcel Identification No.(PIN) '
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: MAY 02 2027
(if well field,one]at/long is sufficient) 22.Ce , don:
N W 1"I.Al a& I1T�
6.Is(are)the wells) OC Permanent or OTemporary Si cure of rti c l a ConVtor D
B signing this form,I hereby t the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or E)No with 1 S4 NCAC 02C.0100 or 15A NCAC 01C.0100 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
9.Total well depth below land surface: �� t (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@2 0'and 2@100) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+' 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
6 12.Well construction method: rotary above, also submit one copy of this form within 30 days of completion of well
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&Iniection Wells: In addition to sending the form to
Q the address(es) above, also submit one copy of this form within 30 days of
13b.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