GW1--06169_Well Construction - GW1_20230922

IF
, WI
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: •
"rile.- WiCA20 .5 14,WATER ZONES ;
Well ontractor Name
��V�� FROM TO DESCRIPTION
3ls� PeV 5- rt. ft. �C-�P�
NC Well Contractor Certification Number / e-2 ! 3 Zit. 36y ft. ��
�/ I 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
James Darby Well Drilling, LLC FROM TO DIAMETER THICKNESS MATERIAL
0 ft. Irt/ ft. 62.r61 in. 5 7IZ \ iPL
Company Name 71 e
10013904 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS 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. j, in.
17.SC
Water Supply Well: FR BE N
M TO DIAMETER SLOT SIZE THICKNESS MATERIAL
I Agricultural OMunicipal/Public ft. ft. in.
®Geothermal(Heating/Cooling Supply) E3Residential Water Supply(single) ft. ft. in.
*Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q ft. ?ci ft. Q_,t _ft 1,I d //it f ,v c %
Si Monitoring Recovery ft. ft. 'r(pcaq lo'N
Injection Well: - ft. ft.
MI Aquifer Recharge 0Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
RI Aquifer Storage and Recovery DISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
n,Aquifer Test QStormwater Drainage ft. ft. 1
®'Experimental Technology Ell SubsidenceControl ft. ft.
!Geothermal(Closed Loop) OITracer - 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) O ft. /,/ ft. Q A_Q /
4.Date Well(s)Completed:? -AO'e..3 Well ID# / ft, 1y ft. 1-0,IA. `t r 1
5a.Well Location: 1 ft. 3-1 ft. T3ru. ^,i /1 rzb C'<-
Danny&Joy Cabrie 39 n, 3/to ft• 6,2 f
Facility/Owner Name Facility ID#(if applicable) 36-a ft.
/00(' ft. ^-'a/%Q f__- ger c_ic-
15316 Thomas Rd. Charlotte, NC 28278 6oe rt. 7ao ft, Cia&�
Physical Address,City,and Zip ft. ft. Ta.,> r;
��'^ _ _ ft.*" -tea
Mecklenburg 21.REMARKS C'`•:•�`t'-' i_.'il:'"f 1!ir- : I
County Parcel Identification No.(PIN) SE p 2, . 2023
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: f
(ifwell field,one lat/longis sufficient) Jr ,r,';(Cil l�I• ✓.<'•" Ui j
22.Certificati n: " - 3
J '� l�sw:t4�::�
N W 7 _/e)- 2-
6.Is(are)the well(s) 0X Permanent or Temporary 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: DYes 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: 7 SUBMITTAL INSTRUCTIONS •
�/
9.Total well depth below land surface: 0� (ft) 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 2@100) construction to the following:
10.Static water level below top of casing: 33 (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 (;n,) 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: r
(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) 6 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:/4ft.- completion of well construction f 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