GW1--05336_Well Construction - GW1_20240906

WELL CONSTRUCTION RECORD(GW-11 0
4
1` ion For Internal Use Only:
411
1.Well Contractor Information:
:71' lt�J 14.WATER ZONES
Well Contractor Name 1 FROM TO DESCRIPTION
4S02 A 29oft. 215 ft. 4.A gpi%
2 ,ft. tic ft' ! Z.a 19�c :ce(e r+ol)
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased we OR LI lt(if ap licable)
James Darby Well Drilling, LLC FROM TO DIAMETER THICKNESS MATERIAL
0 ft. G11 ft. /O tin. atZt t Pvc
Company Name �
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(s e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use):
17.SCREEN
ft. ft. in.
Water Supply Well:
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural °Municipal/Public 0 ft. ft. in.
°Geothermal(Heating/Cooling Supply) x°Residential Water Supply(single) ft. ft. in.
[]Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
I1Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 'LC� ft. 't to►t 12 S ,p .cr.d
Monitoring °Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge °Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
°Aquifer Storage and Recovery [jSalmlty Barrier FROM TO MATERIAL EMPLACEMENT METHOD
O Aquifer Test ❑StormwaterDrainage ft. ft.
°Experimental Technology ['Subsidence Control ft. ft.
Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
°Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) 6 ft. 1 ft.
d
4.Date Well(s)Completed: Well ID# ft. A r ft. Sid {'o Cl
5a.Well Location: q SS ft. 2S5 ft. 3 t^ ro
Darlene Dalton ft. ft.
Facility/Owner Name Facility 1D#(if applicable) ft. ft. t /""
.,1 136 Kings Crest Ct ft. ft. _ `�`�=' 'w�,,
Physical Address,City,and Zip ft. ft. O?A
r��_ s �F
Cleveland 21.REMARKS I
County Parcel Identification No.(PIN) DiAteI �. '`7 UFO
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W 4.44r4„..tri9A:ipailm
g-(/-21+
6.Is(are)the well(s)OX Permanent or ['TemporarySignature of Certified Well 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: °Yes or DI 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,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: � SUBMITTAL INSTRUCTIONS
A
9.Total well depth below land surface: l..J 5 (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@2000'and 2@100) construction to the following:
10.Static water level below top of casing: I (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) 0 Method of test: blow 24c.For Water SutDly&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: 6 oz. 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