GW1--05309_Well Construction - GW1_20240906

I_ a( `4
1
/24 1111111,01111
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor1 Information:
sT 4-n ley S z,C r 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
l 8 A- 3 O ft. 16 7 ft* t tit_
�!]� /00 yo.4-. +-
/�0 ft. /AL ft. .1'QitrC}a^e4 Ack_ =y Cp�tr
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licab e)
James Darby Well Drilling, LLC FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 8', ft. (vie,. in. �D it-al- ►QV
Company Name C,23-04301 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in
Water SupplyWell: 17.SCREEN
FROM It) DIAMETER SLOT SIZE THICKNESS MATERIAL
BAgricultural f Municipal/Public ft ft. in. PA
/�o i3o y At
sad-�
Geothermal(Heating/Cooling Supply) Ell Residential Water Supply(single) ft. ft. in.
IDIndustrial/Commercial 0 Residential Water Supply(shared) 18.GROUT
ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q ft. ,p,/ ft. . Aga/e #/at pe v iC
QMonitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge El Groundwater 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.
QGeothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
QGeothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) iG /
ft. yO ft. ,(r C Cl
4.Date Well(s)Completed:/2'9.2u?-3 Well ID# Lj 6 ft. 75". ft. 46
40
,
5a.Well Location: 7� ft. .;20 ft. G,K IA-a,/P John Weatherford ft. ft. _ �^
Facility/Owner Name Facility ID# S ..(if applicable) ft• ft. 11. ` ( '- Li.
Lot# 10 Colony Ln Cherryville, NC 28021 ft. ft. eA
Physical Address,City,and Zip ft. ft. J E P 0 6 2�2�
Lincoln 21.REMARKS _ I '� `.n,.rrrya_'.9 Ufa
County Parcel Identification No.(PIN) WV MOGI
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certif lion:
N W 12-- -;„„7o.23
6.Is(are)the well(s)JPermanent or OTemporary Signature of Certified Contractor 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: QYes or MNo 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: 320 (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: n (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 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) /(t)0 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: 8 d z- 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