GW1--07269_Well Construction - GW1_20231109

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: I 1
1
C
�h,(�,�'�t� �.��� � S 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
,�;�c-� 1 5-9. 1Sco ft. S�--PN-‘
SS A y�o ft. LI ft. ysCr6'�
NC Well Contractor Certification Number /�/3123 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
James Darby Well Drilling, LLC FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 90 ft. r„lS�yL 5 aa I'tic__Company Name
23-258 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(1.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. [t. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL_
Agricultural 0Municipal/Public ft. ft. in.
ill Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) --g ft. in. i-
*'Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 2-0 ft. 13410 1-}a11-1 7/t i -F€ .5-4+i('e_
NI Monitoring (Recovery ft. ft.
injection Well: _
ft. - ft. -- --- --- - ---
NI Aquifer Recharge 0Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
I I Aquifer Storage and Recovery D Salinity Barrier FROM TO MATERIAL • EMPLACEMENT METHOD
II Aquifer Test IStormwater Drainage ft. ft.
Experimental Technology 0 Subsidence Control ft. ft.
al Geothermal(Closed Loop) (Tracer 20.DRILLING LOG(attach additional sheets if necessary)
II Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) IJ FROM TO DESCRIPTION(color,hardness soil/rock type gain size etc.)
D ft. ' ft. 7 0...4
/�,
4.Date Well(s)Completed: % c2-7•�� Well IN (1,1 ft. .3 ft. Tom\ �
5a.Well Location: .3 9 ft. 6 q ft. B SO-
Paul Durso 6 Li ft. Bo ft. w-e-'h eoc-K
Facility/Owner Name Facility ID#(if applicable) 60 ft. 4- 0 ft. .1 t ,� Ito`�
1631 Pearlstone Ln.Weddington, NC 28104 ft. `9V ft. `
ft. ft. �-,. - J-
Physical Address,City,and Zip _ ,
Union 21.REMARKS „--,''`/ .`i_.I fi' fi z._-,
County Parcel Identification No.(PIN) N O Y L 9 21,n 23
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: 11-1,f' -`-'" - • `'y Lin:,.
N W 7,./..,e,...t....L..
Signature Wel Contractor; Date
6.Is(are)the well(s) -�IX Permanent or JTemporary
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:- QIYes-or XI No- - - 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
'` 1
9.Total well depth below land surface: SO 0 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: /5 GI (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 (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 27699-1636
13a.Yield(gpm) 5"V 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: 16/U2- 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 s. Revised 2-22-2016