GW1-2022-04459_Well Construction - GW1_20220502

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
o e h 13,4-fleil 14.WATER ZONES
r, _ _ I FROM TO DESCR�TION
Well Contractor dame n GjrnQ,p .�
3a h 1 I�fIf1G V e y 6 ft. ;ft. S M1 7ff L TI-Irei 2O*'e.
y� ft. ft j
NC Well Contractor Certification Number a's �� '�rq 15.OUTER CASING for multi-case ld wells OR LINER if a Gcable
James Darby Well Drilling LLC J FROM TO DIAMETER THICKNESS MATERIAL
V ft. &9�fL in. 6 a
rr ,
Company Name 16.INNER CASING OR TUBING, 'eothermal closed-loo
2.Well Construction Permit# SW20-0096 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC.County.State,Variance,etc.) ft. ft in.
ft ft in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SI7� THICKNESS MATERIAL
Agricultural QMunicipal/Public It. ft id•
Geothermal(Heating/Cooling Supply) tj AEsidenlial Water Supply(single) ft. ft. inl
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q It. O f fL
Monitoring []Recovery ft. ft.
injection Well: It. ft
Aquifer Recharge []Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test []Stormwater Drainage ft. ft.
Experimental Technology []Subsidence Control ft. ft.
Geothermal(Closed Loop) []Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soiVrock type,grain size,etc.
RGeothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ft ft.
r
4.Date Well(s)Completed: �9 Well ID# *o ft• Q ft
5a.Well Location: v ft ft. 1*01./
Alan Fletcher ft. ft. r.
Facility/Owner Name Facility ID#(if applicable) 410 Alf
Well#2:960 Freeman Town Rd., Rutherfordton, NC 28056
Physical Address,City,and Zip ft. ft.
Rutherford 21.`REMARKS
County Parcel Identification No.(PIN)
1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -
(if well field,one lat/long is sufficient) 22w�
N �1
6.Is(are)the well(s)oX Permanent or []Temporary Sign re o erti cll Contra for Da
By igning this form,I hereby •rt�that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or X[]No w h 15A NCAC 02C.0100 or] A NCAC 02C.0200 Well Construction Standards and that a
tf 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 921 remarks section or on the back of this form.
23.Site diagram or additional well details:
S.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-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: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@I00� 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 Iniection 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&Iniection 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: 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