GW1-2022-00156_Well Construction - GW1_20221219

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: j
6,ePh 6&dkiz 14.WATER ZONES
FROM TO DESCRIPTION
Contras or Name
F&.-4 ( la�r9�2Z ft. °ft. -& 22a
i
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells ss OR LINER if a licable
James Darby Well Drilling LLC FROM To DIAMETER THICKNEMATERIAL
Company Name t D it. .2 fL in 39 y-
^ i A 16.INNER CASING OR'TUBING eothermaI closed-loop)
2.Well Construction Permit#: a �( FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) fit. fL j, in
3.Well Use(check well use): ft. fL is,
17.
Water Supply Well: FROM E TO DIAMETER SLOT SIZE THICKNESS MATERIAL
I Agricultural [:)Municipal/Public ft. ft. in.
I Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. fL in.
I Industrial/Commercial idential Water Supply(shared) 18.GROUT
71 Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: - v, fL' ft 6 /fe QV r
I Monitoring DI Reave& Q 7 ft. ft.
Injection Well:
fit. fit.
I Aquifer Recharge i''i filioini&watardlemediatio&mrt
19.SAND/GRAVEL.PACK(if applicable)
I Aquifer Storage and Recovery [:]SaliniLy B-iei v FROM TO MATERIAL EMPLACEMENT METHOD
I Aquifer Test 3Stormwater Drainage ft. ft.
I Experimental Technology Subsidence Control ft. it.
I Geothermal(Closed Loop) ©II Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) I Other(explain under#21 Remarks) FROM ft. TO DESCRIPTION color,hardness,soit/rock type, rain size,etc.
fL 2 svv?
4.Date Well(s)Completed: 9 .?l x- Well ID# it. ft. or�� L• S 6i�
5a.Well Location: it. Q ft �
Travis Steele ft' 1 1-/0 ft. r/ (r•�i C/
Facility/Owner Name Facility ID#(if applicable) fit.
9928 Lancaster Highway, Waxhaw NC 28173 ft. ft.
Physical Address,City,and Zip
Union ` 't7 -vv,A 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W
6.Is(are)the wells) JZi Permanent or OTemporary Si re of ertified Well Cpntjfictor Da
I�
By signing this form,I here certifyi!that the well(s)was(were)constructed in accordance
7.Is this a repair.to an existing well: ni Yes or X No w h 15A NCAC 02C.0100 a 15A 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 also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 7 t7( (fit.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-"` _@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 Servicei Center,Raleigh,NC 276994617
11.Borehole diameter: 6 1/4 (;n,) 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) 5�TP ►I Method of test: blow 24c.For Water Suably&Inleection 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.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resour i esi Revised 2-22-2016