GW1--04368_Well Construction - GW1_20240723

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
I.Well Contractor Information:
STF}n ley s etz,e 2 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
VA Is-vfl-tivt.AL,
c2. I S S A FA X-ell ft. ft.
NC Well Contractor Certification Number 6/as1,2il 15.OUTER CASING(for multi-cased wells)OR LINER(if appelicable)
James Darby Well Drilling, LLC FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 9 7 ft. CO 4 in. s p.K_2,i eV i�
Company Name
14163 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.UIG County,Stale. Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft. in.
QGeothermal(Heating/Cooling Supply) ig Residential Water Supply(single) ft, ft. in.
0Industrial/Commercial DResidential Water Supply(shared) ts.GROUT
)Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 30 ft. Aiaat P/l pd t/e
Monitoring QRecovery ft. ft. T
Injection Well: -
ft. ft.
°Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery ()Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
°Aquifer Test DStormwater Drainage ft. ft.
OExperimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,sail/rock type,grain size,etc.)
OGeothermal(Heating/Cooling Return) ['Other(explain under#21 Remarks)
Q H. 9 2 ft. 4-c4•tm e,J-- RdCJ tJ
4.Date Well(s)Completed: 63.2a2`1Well ID# p� ft. 3 5�3 ft. G k 1:1. ,4, -
5a.Well Location: / rt. H.
Scott Lee ft. ft. - ` `r IL.
Facility/Owner Name Facility 1D/t(if applicable) ft. R. -3U L 2 t' 2024
125 Adcock Bluebird Ln Belmont NC 28012 ft. ft.
-- 1 T-.---..c.. , 'JpIC
Physical Address,City,and Zip ft. ft. (yW,:d 3r
Gaston 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.Certificatio
N W _ --..2a2,,(/
6.Is(are)the well(s)0Permanent or Temporary Signa of Certified Well Co for Date 7
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: °Yes or )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 details. You may also attach additional pages if necessary.
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: SUBMITTAL INSTRUCTIONS
L'
9.Total well depth below land surface: 3 7 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@200'and 2@100') construction to the following:
10.Static water level below top of casing: V (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) 7 Method of test: Blow 24c.For Water Supply& Injection Wells: In addition to sending the form to
t-, the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: ! 02- 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