GW1--06487_Well Construction - GW1_20231002

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
I
•
'4ai-/i If/i' boi5 14.WATER ZONES
WeIlContractorName FROM TO DESCRIPTION
61'3153" FA /2 71/7-3 /_15-ft. /34 ft. /S M
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells)OR LINER(if ap livable)
James Darby Well Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
Company Name d ft. /� ft. /.ty. in. /]/!a( rvc_
176039 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. i' in.
17.SCRE
N
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public 0 ft• ft. in.
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
-I Industrial/Commercial ]Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. 20 ft. 6k.k /f�..,
Monitoring Recovery ft. ft. Yt col `
Injection Well:
ft. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery (Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft. I
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) [Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) DESCRIPTION color,hardness,sod/rock tysod/rock grab size,etc.)
ft. /4 ftf_e . We-)
4.Date Well(s)Completed: 2V--�� Well ID# IG ft. 30 ft. \ JO t
5a.Well Location: 3cQ ft. / i_ ft. 1 ('t
Paul Vogt ft. 1/11) ft. 157n4A, Wect eOc 4-
Facility/Owner Name Facility ID#(if applicable) Po ft. /65- ft' •171,`� Irf7 Gl�s
108 Tibor Drive ft. ! ft.
t�t
Physical Address,City,and Zip ft ft rn,i'"'p t°i"I I mo'
Cleveland 21.REMARKS FA.L_�,+i..-i+ V x°.LI
County Parcel Identification No.(PIN) I1. OCT
T v 2 L(Z3
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I
(if well field,one latilon sufficient)•is 22.Certification: IIS$tizt��"r-=�`=t''Pi;,w:f�'"a:v?��'tir'n
N - ' ?gabs''';'
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6.Is(are)the well(s) Permanent or [jTemporary S attire of Certified Well Contractor Date
_ By signing this form,I hereby certtfr that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: lYes or DNo 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: /'s 4 (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: j
10.Static water level below top of casing: A
(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/ n.) 24b.For Injection Wells: In addition'4 (i n'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
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13a.Yield(gpm) /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: S5Z- completion of well construction to the county health department of the county
where constructed. 1 '
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources , Revised 2-22-2016