GW1-2022-04460_Well Construction - GW1_20220502

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
�� pr,�KIn me y
Job 4 a �5 CBIrFROM
ATER ZONES
IF TO DESCRIPTION
Well Contractor Name
ftS pii4/l f-me_7i/rLZOl��r' 306 ft 5 17, WTarC .7~
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
James Darby Well Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
0 ft. h3 ft . s in- V
Company Name
SW20-0096 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THIc[avess MATERIAL
in.
List all applicable well construction permits(i.e.UIC,County.State.Variance,etc.)
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THI KNESS I MATERIAL
Agricultural QMunicipal/Public ft. ft in•
Geothermal(Heating/Cooling Supply) E)Residential Water Supply(single) ft. ft. in:
Industrial/Commercial DResidential Water Supply(shared) 1S.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT MET�H/OD&AMOUNT
Non-Water Supply Well: v ftaW
r Qvr A7 ff
Monitoring DRecovery
Injection Well: ft. ft
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test D Storrriwater Drainage ft. ft.
Experimental Technology D Subsidence Control ft. ft.
Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) FlOther(explain under#21 Remarks) FROM ft. TO ft DESCRIPTION(color,hardness,soil rocktype, rain size,etc.)
O
4.Date Well(s)Completed: Well ID# ft' I 6<ft. tin
Sa.Well Location: '70ft. ft.
a
Alan Fletcher 30 ft' 1 0 ftV 126 1<
Facility/Owner NameFacility ID#(tfaPPlicable) 40 f. ft &,k R Sa/ 1-X6.
Well#1:960 Freeman Town Rd., Rutherfordton, NC 28056 S'ft. ft. &01✓rl
Physical Address,City,and Zip ft. i• %ft. r
Rutherford 2I.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: NARY U 2 202?
(if well field,one lat(long is sufficient) 22.Certification•
N W r 46'"rr 'r�1t; " ' Ali'
6.Is(are)the well(s)OX Permanent or DTemporary c o erti ell Con ctor Date
ing B sign this form,I Itereb certify that the well(s)was(were)constructed in accordance
37 ig.
7.Is this a repair to an existing well: Dyes or X)No with 1 SA NCAC 02C.0100 or 1 SA 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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may alsa attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: -0 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(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,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/4 (in.)' 24b.For Infection 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) a GPI 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 Amount13 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