GW1--03431_Well Construction - GW1_20230516

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: Fae
C - x V\Ct-r� '- r L\-\o 15 3 14.WATER ZONES
Well Contractor Name FROMM To DESCRIPTION
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 TO DIAMETER THICHIVF.SS MATERIAL
Company Name 6 It. is ft. L9,14 in,
22-471 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICENESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FFR7.OS i REE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E)Municipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in•
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irri ation .FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. "d\® f- , ,eA,4ra�Z
Monitoring ORecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
Aquifer Storage and Recovery [3Salinity Barrier FROM TO MATERIAL EMPLACEMENT ME-MOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology E3Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) _ Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc
f1 ft. / ft. �1
4.Date Well(s)Completed: ✓� d Well ID# uL V ft. I15t & -'4L vj-&
5a.Well Location: I u
ft. o fL '-rn =
Ramin Raymond Sayadpour ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
6212 Highview Rd Waxhaw, NC 28104 ft. ft. �� � a; _�'
Physical Address,City,and Zip fL ft. P 9
Union
21.REMARKS MAY 1
County Parcel Identification No.(PIN) v 'a7r•.r ^,•e,`T.- 11 `
-
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one latllong is sufficient) 22.Certification:
4� 6
6.Is(are)the well(s)oPermanent or DTemporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or jNo 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 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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: i� l SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: y (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iit different(example-3@200'and 2@100� construction to the following:
10.Static water level below top of easing: I (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 1/4 (in.) 24b.For Iniection 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) O v Method of test: BLOW 24c.For Water Supply&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: 1a dL- 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