GW1-2023-02179_Well Construction - GW1_20230306

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
Ilt
`�(� ft. ft 6, 9Wl
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
James Darby Well Drilling, LLC FROM TD DIAMETER TffiCKNESS MATERIAL
Company Name D ft. 1 ft. l_t* in. 2-it
13909 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO I DIAMETER TRICKINESS MATERIAL
List all applicable well construction permits(i.e.VIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public 0 ft. ft. in.
—Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
—Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT b1E1fIOD&AMOUNT
Non-Water Supply Well: ft. -)10 ft. ( ,1Zt W ,6 Fe4/ _A,
Monitoring DRecovery ft. ft.
Injection Well:
_ ft. ft.
Aquifer Recharge Groundwater Remediaiion
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM To MATE[UAL EMPLACEMENT METHOD
Aquifer Test E]Stormwater Drainage ft. ft.
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) OTraeer 20.DRILLING LOG attach additional sheets if necessary)
—Geothermal(Heating/Cooling Retum) ^Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soi0rock type rain sae,etc
V
fl ft. % ft.
4.Date Well(s)Completed: 1 21 ��—Well ID# it. i,U// ft W&lG�( 1rjti—_1
Sa.Well Location:
ft. ft.
Facili /Owner Name Facility ID# ifa licable ft. ft <„• {; a, ;
ty tY ( PP )
I1 "Fr Cr-. " ck00,5 nc 2803V ft. ft
Physical Address,City,and Zip ft. ft. l i t
G- L_ 21.REMARKS VA
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one laUlong is sufficient) 22.Certification:
N W 2I.2-2-
6.Is(are)the well(s)igPermanent or ©ITemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E)Yes or [NNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the mature 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
1
9.Total well depth below land surface: ��S (f0 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3 a 00'and 2Q@�100') construction to the following:
10.Static water level below top of casing: 1 (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.
(� ) 246.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
J
13a.Yield(gpm) Method of test' Blow 24c.For Water Sunaly&Injection 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 66rz- 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