GW1--06457_Well Construction - GW1_20231002

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
CA4 rl/e 114:O a b . 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
a3/SJ TOI)Cei W ft 14-7 ft. /4i
z3 ft. ( ft.
NC Well Contractor Certification Number q/Zs/ 15.OUTER CASING(for multi-cased wells)OR LINER(if ap livable)
James Darby Well Drilling, LLC FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. /32_ ft. �,y4 in. G p eem .n v
�� 3�f/7 16.INNER CASING OR TUBING(geothermal closed-loop) N
2.Well Construction Permit#: /I 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. in.
Water Supply Well: FROM EN
TO DIAMETER SLOT SIZE THICKNESS MATERIAL
i Agricultural DMunicipal/Public ft. ft. in.
MI Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
*I Industrial/Commercial Residential Water Supply(shared) 18.GROUT
I Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 3-0 ft. 13a/1 it 14,1w2
, /c.. ts f'Q
*I Monitoring Recovery ft. ft. [���' �f�f'
Injection Well:
ft. ft.
*Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
HIAquifer Storage and Recovery. D1Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
MIAquifer Test DStormwater Drainage ft. ft.
•Experimental Technology 0 Subsidence Control ft. ft.
*Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO 'DESCRIPTION(color,hardness,soiVrock type,grain size,etc.)
I 1 Geothermal(Heating/Cooling Return) D Other(explain under#21 Remarks)
co ft. �$ /ft. �_�, Q L
4.Date Well(s)Completed:£r'26'23 Well ID# is .C�ft. Ye, ft. ¢ W- t-�5Di ( )
5a.Well Location: y g ft.
/4 ft.
r3 «'+N, 5 b /
Sabrina Coulston. S$ ft. /7-)--f` ._W ..Q gook-
Facility/Owner Name Facility ID#(if applicable) /7..x.21. I�q Q0 ft. igo`�
r
6718 Timahoe Ln Charlotte, NC 28278 O I/t 2 ft. ft.
Physical Address,City,and Zip
Mecklenburg 21.REMARKS t''67,.�',.a L -I, +" a-,
County Parcel Identification No.(PIN) O C T 0 2 2023
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: i,t;
(if well field,one lat/longis sufficient) ` 'T'.2 t C f i�t;rti.^7.',.t
22.Certify lion: (n7�I ,,
N W
G-?-lt-z3
6.Is(are)the well(s)3Permanent 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: ]Yes or jNo • with 1SA 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: Q2 bt (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@I00') construction to the following:
10.Static water level below top of casing: V (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service i enter,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,lUnderground Injection Control Program,
FOR WATER SUPPLY WELLSONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) I U 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:/(Opp completion of well construction to the county health department of the county
where constructed. 1 I
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016