GW1-2022-04464_Well Construction - GW1_20220502

Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well 'Contractor inf((4ormation:
Y�tAf 14.WATER ZONES
Well Contractor Name - FROM I TO DESCRIPTION
� 9 /�
f ��' /�n Z f� r7`GJ C--�Ltn
NC Well Contractor Certification Number I �}, ft � ft {,��l G�7�
15.OUTER CASING for mul Vti-cased wells OR LINER if a G Aa
James Darby Well Drilling L LC FROM TO DIAMETER THICKNESS MATERIAL
f t % ft. l3 ! in ;r� 7.
Company Name "
20-510 16.INNER CASING OR TUBING eothermaI dosed-loop)
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) h fL in.
3.Well Use(check well use): ft. I ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
0Agricultural E)Municipal/Public 0 fr, ft, in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) R ft in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
- Irrigation FROM TO MATFRLAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: �,� fL cal: fr ,.ha,�p 1e. 1 tuil�
Monitoring DRecovery ft. ft.
Injection Well: ft fL
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology Subsidence Control & &
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additionalsheets if necessary)
Geothermal(Heating/Cooling Return) rlOther(explain under#21 Remarks) FROM
TO DESCRIPTION color,hardness,soillrock a in sae,etc
l X fL fc
4.Date Well(s)Completed: '3- \ Well ID# '
ll
5a.Well Location: )L f JH ft.
Mike and Chelsea Caulder TA fL )IX, ft.
Facility/Owner Name Facility ID#(if applicable) ft. &
6002 Pleasant Grove Rd., Waxhaw NC 28173 ft. ft.
Physical Address,City,and Zip ft. ft.
Union 21.REMARKS
County Parcel Identification No.(PiN) MAY O 2 2072
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: t
(ifwell field,one latAong is sufficient) 22.Ce cation:
n>t1ETO
MA PROCESFdu UN
6.Is(are)the well(s)oPermanent or 13Temporary Signature of Certified Well Contractor Date
13v.signing this form, l hereby certify that the well(s)was(were)constructed in accordance
7.is this a repair to an existing well: DYes or !X No with 15A NCAC 02C.0100 or ISA 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 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: 'UV (ft) 24a. For All Wells: Submit this.form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3J7a200'and 2 cr,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 A (in.) 24b. For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: 7y
rotar above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1 o to Method of test: blow 24c. For Water Supply&lniection Wells: In addition to sending the form to
HTH the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: �L 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