GW1--05280_Well Construction - GW1_20230814

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
/r-el Iey Kt �01-Zen 14.WATER ZONES
Well Contractor Name / FROM TO ./D�E,SCRIPTION /
2t 8 5 A -Food xSsH. ?S1 ft. TK t!>GQ6Q,k /��yp1w
�7/ 3 b3 ft. So fL it �t a/6 It I'
NC Well Contractor Certification Number i /(t/2-3 15.OUTER CASING(for multi-cased wells)OR LINER(if ap [feeble)
James Darby Well Drilling LLC { FROM TO DIAMETER THICKNESS MATERIAL
ft. In.
Company Name a ft. �� f s�Q y, v
10013798 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(.e.UIC,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 JMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
*gation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. -I fL FJs le Pl u S+ 1°O U/4
Monitoring Recovery ft. fL /
Injection Well: ft. fL
Aquifer Recharge 0 Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery D Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test IJStormwater Drainage ft. ft.
Experimental Technology D Subsidence Control ft. ft.
Geothermal(Closed Loop) j jTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type.grain size,etc.)
-Geothermal(Heating/Cooling Return) [Other(explain under#21 Remarks)
// 0 ft. /2 ft. Z' -sZ ,< e.ja4..
4.Date Well(s)Completed:ld i20 Well ID# a ft. C/ tt A4`f wipe Cis_y
8"
5a.Well Location: / ft. -,. 1 ft. 5 n H..n,-l-� ` !
P &N Homes ft. ft. , s ;_t �„ e+4 n7.c'
Facility/Owner Name Facility ID#(if applicable) ft ,
11004 Green Heron Ct ft. ft. AUG 1 Z023
IL ft.Physical Address,City,and Zip Irrk;a.f;;t'i,^.rl .3rrr ,,%.-,-,. � Ur'
Mecklenburg 21.REMARKS [ua?.:,L-t"-j
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.Certifi
N W / 6f.e-A-- k auk
6.Is(are)the well(s) Permanent or Temporary Signature of Certified weltractor Date
X
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: IYes or ONo 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 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: 3 2 Y (fi-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 200'and 2Q100') construction to the following:
10.Static water level below top of casing: -/ I (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 Injection 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 11
13a.Yield(gpm) ? 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
13b.Disinfection type: HTH Amount: 7 0 7- completion of well construction to the county health department of the cow
where constructed.
I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revise