GW1--00336_Well Construction - GW1_20240112

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: ,---
1.Well Contractor Information:
aha,—/.S'€_. difr,L yts 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTIO
3tcc- 1I/21/2,3 96 ?6,ONN A—
66 ft. /to 7 ft. 3 cps
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
James Darby Well Drilling, LLC FROM TO DIAMETER THICKINESS MATERIAL
0 ft. 7ft.
Company Name & 'Ai)? in. ej-D��` p t2
1 00 1�� 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 13 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft i in.
3.Well Use(check well use): ft ft in
17.SCREEN
Water Supply Well: FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
7 W Agricultural OMunicipal/Public o ft ft. in:
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft g in;
._` Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
1othermal
on-Water Supply Well: U R ft. t�divl 2 (. GGCr f��' �'jy�j fL'
Monitoring OGroundwater Remediation
Recovery ft ft.
_ njection Well: ft ft.
19:SAND/GRAVEL PACK(if applicable)
Aquifer Recharge
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
D
Experimental Technology OlSubsidence Control ft ft.
(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) OOther(explain under#21 Remarks) FROM TO DESCRIPTION(co ,hardness soi0rock type,grain size,etc.)
D ft 76 ft /ljor 724,f` C 4,7
4.Date Well(s)Completed:/! - --,7--7 Well ID# C1�/J', ft. rp ft. Tj11n. Sat (
5a.Well Location: 7 j ft / ft 't iu r <c t 1'
Kelly Carprio s-( ft. (0..2..ft -gala Wg 4 c-t
Facility/Owner Name Facility ID#(if applicable) 6 2 t. - ft Gri2-/ oo'c rr
5506 Mt. Olive Church -Rd. ft ft. TT ,7--\`;�e ,'-,
Physical Address,City,and Zip ft. ft. 11.;,y� i.,,L.:a . Li
Mecklenburg 21.REMARKS
J,yiv t 4 Z624
County Parcel Identification No.(PIN)
inn rrr,c.ti".it 1�f:-r?`�1aRA%a Utt.X
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ,, .
(if well field,one lat/long is sufficient) 22.Certification: I ['r�lv l ri"� G
N W : ma
- s i� • ti-
6.Is(are)the well(s) Permanent or Temporary rgrature o Certified Well Contractor Date
iX'
By signing this form,I hereby certlfr that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Oyes or XONo 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: 0 V (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'andj2@l00') construction to the following:
✓
10.Static water level below top of casing: 5 (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 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
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: /6U2— completion of well construction to the county health department of the county .
where constructed.
I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016