GW1--03090_Well Construction - GW1_20240522

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: `}+
5_7Ljq y�.I7 ��� 1 — fA 14.WATER ZONES
Well Contractor Name 1 FROJt 10 DESCRIPTION
AI l 8J A- _O ft. 51 ft 4 ice -- if 9p"►
NC Well Contractor Certification Number
ft. /D S ft. 2 i vn,e s , pyY7
15,OUTER CASING(for multi-cased teeth)OR LINER(if sip tea le)
James Darby Well Drilling LLC FROM TO DIAMETER_ THICKNESSIS NI 1,IIRI AL —1
Company Name T 1 © H. 73 ft. /4 in. `DR—may1 so ve
I' 1 z� 1 16.INNER CASING OR TUBING(geothermla(geothermalclosed-loop)
2.Well Construction Permit#: 11 FROM TO DIA>tf:TER THICKNESS MATERIAL
List all applicable well construction permits Be.U1C,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
,,Well: 17.SCREEN
Water Supply FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
°Agricultural °Municipal/Public ft. ft. in.
()Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft, ft, In,
Qlndustrial/Cornmercial Residential Water Supply(shared) is.GROtrr
°Irrigation FROM I'O MATERIAL EAI PI:%CF MEN I MEIHOD&AMOUNT
Non-Water Supply Well: D ft. Zit ft. /-, V
Lie �D/a , P,U iz
ft.
Monitoring Recovery ft.
Injection Well:
ft. ft.
Aquifer Recharge °Groundwater Remediation Iq,SAND/GRAVEL PACK(i[trppUsabk)
Aquifer Storage and Recovery in Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
()Aquifer Test DStormwater Drainage ft' fL
()Experimental Technology °Subsidence Control ft. ft
°Geothermal(Closed Loop) °Tracer 20.DRiLLINC LOG(attach additional;beets if necessary)
FROM TO DESCRIPTION(color,hardness.sorb rock type,groin sire.etc.)
©Geothermal(Heating/Cooling Return)/ [Other(explain under#21 Remarks) d fL �2 5e� �
4.Date Wells)Completed:,{i.-- y Well ID# ,`s ft. 6al, ft. r[OsJ) SIF�y e+ lm y
51.Well Location: le 0 ft. to b h ch ne• 24
Sam Barnette /off' l /3 It &I(14ti .
Facility/Owner Name Facility iD#(if applicable) ft. ft.
2130 Babbling Brook Ln ft ft ,
Physical Address.City,and Zip ft. R.
• t.`.1 fir: r
Gaston 21.REMARKS
County Parcel Identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: LriJ(. R lei
(if well field,one lat/long is sufficient) 22.Ce e y
N W -�(-� _/
6.Is(are)the well(s)OPermanent or °Temporary Si t fCertifi ctor� Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ()Yes or ElNo with iSA NCAC 02C.0100 or 1SA 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 1/21 remarks.section or on the back o/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 l GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: �j SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1q ✓ (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple;mils list all depths if different(example-3Q200'and 2@1000') construction to the following:
10.Static water level below top of casing: 30 (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 1/4 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) 30 Method of test: Blow 24c.For Water Sunoly&Iniection 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: y 0 Z- completion of well construction to the county health department of the county
where constructed.
Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016