GW1--03433_Well Construction - GW1_20230516

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
1 91/� 14.WATER ZONES
f FROM TO DESCRIPTION
o ctor 1,71
Well C me _ f' JC ft.
1—n // 3)1& IA3 ft. IL
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a licable
James Darby Well Drilling, LLC FROM To DrAMETER THICIINESS MATERIAL
0ft yr, IL .2 S in. -50
Company Name 16.INNER CASING OR TUBING(PeothermaI closed400
2.Well Construction Permit#: 21-278 FROM TO1 DIMLETER I THICKNESS MATERIAL
List all applicable well construction permits ri.e.UIC,County,State,Variance,etc.) It.
t IL in.
3.Well Use(check well use): it. ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE TIICKNESSI MATERIAL.
Agricultural OMunicipal/Public ft. fL in.
Geothermal(Heating/cooling Supply) X Residential Water Supply(single) ft. ft. in.
dustrial/Commercial Residential Water Supply(shared) 18.GROUT
ation FROM I TO MATERIAL EMPLACEMENT HOD&AMOUNT
Non-Water Supply Well: b it. O It. h VV 1
Monitoring []Recovery ft. ft.
Injection Well: ft. ft.
Aquifer RechargeGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test IDStormwater Drainage ft. ft.
__ Experimental Technology D Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessa ' _
_ FROM TO DES I'TTON color,hardness,soil/rock e, rain siu,etc.
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ft. 4 ft.
B,
4.Date Well(s)Completed: Well ID# ft. fl. Soy
Sa.Well Location: ft36 IL 010
Chariton Plyler f° fQ 1
Facility/Owner Name Facility JD#(ifapplicable) ft ft.
302 Waxhaw-Indian Trail Rd.Wesley Chapel, NC 28104 ft.
Physical Address,City,and Zip ft. E�f:
�aag 21.REMARKS,
Union )03
CountyParcel Identification No.(PIN) " ^^
IV v LJ
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification II1(s�i f ^.l �r^.rryry:,. l f's.'�
5::::
N W r / �' "•�
6.Is(are)the well(s)oPermanent or Temporary
Si re o rfi Con or Da
ing this form,I hereby ertify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes 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 nature ofthe copy ofthis 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: OR (fl) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifjerent(example-3 00'and 2@1100� construction to the following'
10.Static water level below top of casing: 1 If ot.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276994617
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 276994636
13a.Yield(gpm)_'15 0 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: �0 r completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016