GW1-2023-02235_Well Construction - GW1_20230307

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:'
G1��r 1 t Z N CGS 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name t L) ft, I Ic�'2 ft. W'jvl
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 THICKINESS MATERIAL
Company Name v W
22-221 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits ri.e.UiC,County,State,Variance,etc.) ft. ft. in•
3.Well Use(check well use): ft. ft. in.
17.
Water Supply Well: FROME TO DIAMETER SI.OTSIZE THICKNESS M1IATERIAL
NAgricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) IS.GROUT
— Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. IL Y `,-
Monitoring QRecovery ft. ft.
Injection Well:
ft. ft
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)_
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT AIETHOD
Aquifer Test DStormwater Drainage
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) ❑ITracer 20.DRILLING LOG(attach additional sheets if necessary)
RGeothermal(Heating/Cooling Return) FlOther(explain under#21 Remarks) FROM To DESCRIPTION color,hardness,soil rock S rain sue,etc
ft. ft. Q /{C
4.Date Well(s)Completed:��'13 ' Well m#
5a.Well Location:
Gairy James
Facility/Owner Name Facility ID#(ifapplicable)
8780 Rea Rd., Waxhaw, NC 28173 ft. ft.
Physical Address,City,and Zip
Union 21.REMARKS o,
I', i 0 , ^L J
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one fat/long is sufficient) 22.Certification:
N W
6.Is(are)the well(s) X Permanent or Temporary Si ature 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: [3Yes or X)No with 15A NCAC 01C.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 nature of the copy of this record has been provided to the well owner.
repair under 421 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: r SUBMITTAL INSTRUCTIONS
/-`,.
9.Total well depth below land surface: �l0 J (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@100D 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) U Method of test: blow 24c.For Water Supply&Infection 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: 66r-1 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