GW1--03141_Well Construction - GW1_20240522

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WELL CONSTRUCTION RECORD (GW-1) -
For Internal Use Only: t
1.Well Contractor Information: Fax-et)!
5''11yst .}� - s/i s/Z4
� ,ley S�t�4 14.WATER ZONES
Well Contractor Name / FROM TO DESCRIPTION
07{ �� l� 6/Oft- A I ft. f-1�. ,eoe-C
NC Well Contractor Certification Number 5 g lU ft 1 `Zft. ycased l R� /
15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
James Darby Well Drilling, LLC FROM TO DIAMETER/ THICKNESS MATERIAL
o ft. 43 ft. to Y in.
n 5DR_..21 AD e
Company Name
23-241 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. is
Well: 17.SCREEN
Water Supply FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL. _
DAgricultural DMunicipal/Public 0 ft* ft. in.
Geothermal(Heating/Cooling Supply) EiResidential Water Supply(single) ft. ft. in. '
Olndustrial/Commercial DResidential Water Supply(shared) 18.GROUT
I1Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNTD{
Non-Water Supply Well: 6 rt.;-( ft' A /e P 107 P o u re. 1 dV S
Monitoring Recovery ft. ft. /
Injection Well: ft. ft.
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
0 Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
OGeothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
Other explain FROM TO DESCRIPTION(color,hardness,soiVrock type,grain size,etc.)
DGeothermal(Heating/Cooling Return) ( p under#21 Remarks) ft. /2 ft. �eL d
4.41
4.Date Well(s)Completed: fr..16/CfLY Well ID# /2. ft. 3 5 ft. c/Q-__J uM� 11 7 FZoe k.
5a.Well Location: 55 f• ao6 ft. e.2 *` T'i 14-►t ` ii�`
William Herlong ft. ft.
Facility/Owner Name Facility 1D#(if applicable I ft. ft. - ,
7012 Waxhaw Crossing Dr. Waxhaw, NC 28173 ft. ft. '' `-
Physical Address,City,and Zip ft. ft. /1 Y 2 7,', (j 7
Union 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certifi J. .n:
N W j/JJ� ,Jl'30 �? 2Y
6.Is(are)the well(s)fx Permanent or Temporary Si. : •. of Certified Well C reactor Date
By signing this form,I hereby cent-A,that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or No with 1SA NCAC 02C.0100 or ISA 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: tt,1 e 0 (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: (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 (i n.) 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) 1 S Method of test: Blow 24c.For Water Suprily & 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: 0 ' 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 Revised 2-22-2016