GW1--03143_Well Construction - GW1_20240522

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
5-1f}n'Oe/ Se:±Z,e4 14.WATER ZONES
FROM TO
Well Contractor Name DESCRIPTION
� ' �� 9rft. 0/9 ft. -{�tpc,`JTIO.Nit=� ")l 1 g E
29f ft. A96 ft. t t w//1 5P'
NC Well Contractor Certification Number 15.OUTER CASING(for multi-eased wells)OR LINER(if ap licable)
James Darby Well Drilling, LLC FROM TO DIAMETER THICKNESS MATERIAL
a
Company Name ft. /3 ft. / in. Ms 2.I p v C
24-38 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.UDC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft ft. in.
17.SCREEN
Water SupplyWell:
FROM TO DIAMETER SLOT SITE THICKNESS MATERIAL
Agricultural ©Municipai/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT� METHOD&AMOUNT
Non-Water Supply Well: O ft' /'.' ft' b le_ pi uj Y-p D U( .
Monitoring ORecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0 Stormwater Drainage ft. ft.
Experimental Technology ()Subsidence Control ft. ft.
Geothermal(Closed Loop) QTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soil/rock type,grain size,etc.)
0 ft. pi ft. Rem C 1 6-
4.Date Well(s)Completed: 2~'2-DO1.yep ID# 1 / ft. 37 ft. eel)o/J e Rock
5a.Well Location: s'i ft. 4o $ ft. .` R 1y� e�'U neC
Richard Moore eoSft. L/03 ft. C�rzl4n:+e._
Facility/Owner Name Facility ID#(if applicable) it. (t.
2407 Fletcher Broome Rd. Monroe, NC 28112 ft. ft.
ft. ft. 1"GY 7, S LO?4
Physical Address,City,and Zip ,
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.Ce . if 1.
►,
6.Is(are)the well(s)0Permanent or Temporary Signature of Certified We tractor % Date
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: DYes or ONo with ISA 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: y t)3 (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(a_200'and 2@100') construction to the following:
10.Static water level below top of casing: JI/ (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 Iniection 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) I X 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: 5 1 2- 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