GW1--05333_Well Construction - GW1_20240906

WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well Contractor Information: sink- 7/�y/
el," , N U t.) 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name f 2t 1 ft. 1 21\ N. 1C-0/1/1
3(55- gib ft. ggelft. (4F,
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap icable)
James Darby Well Drilling, LLC FROM TO DIAMETER THICKNESS MATERIAL
IC) ft. i-7 ft. 6,( % in. <J - ` Q(.2
-
Company Name 14314
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.UJC,County,State,Variance,etc.) ft. ft. in.
-
3.Well Use(check well use): ft. ft in
17.Water Supply Well: FROM
PPY FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipal/Public 0 ft. ft. in.
®Geothermal(Heating/Cooling Supply) IDResidential Water Supply(single) ft. ft. in.
RIndustrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD,&AMOUNT��
Non-Water Supply Well: 0 it. ft. 1e,�.cli-Ae \��V fj4 �)„tyV4fJtt�
▪Monitoring )Recovery ft. ft. V'�l �"
Injection Well: ft. ft.
)Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
ID Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL 1 EMPLACEMENT METHOD
QAquifer Test []Stormwater Drainage ft. ft.
)Experimental Technology DSubsidence Control ft. ft.
)Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
)Geothermal(Heating/Cooling Return)tu y❑Other(explain under#21 Remarks) 0 ft. (8 ft. �, 1
4.Date Well(s)Completed:7-)z l Well ID# Q ft. ��ft. Sat
5a.Well Location: �U2ft. 3 )4. iStNt(. So;
Clayton Homes/G Phillips 3`) ft' 8 7 ft' .5nMA Wes1.04,l.rQ r --
Facility/Owner Name Facility ID#(if applicable) 8 7 ft. Z,C ft. G go124 Spratt Dr., Mt Holly, NC 28120 ft. � ft.
Physical Address,City,and Zip ft. ft. _ ` �j 1�.�
�as 21.REMARKS 0 6 202 r
County Parcel Identification No.(PIN)
lfl Ortf;iiien P•rrsrs._-
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: aNG � 1 U�
(if well field,one lat/long is sufficient) 22.Certification:
h `
N W _ly��� _ 7 -3 .-
6.Is(are)the well(s)Ox Permanent or )Temporary gnature of Certified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: )Yes or xQNo 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
9.Total well depth below land surface: 3 O0` (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 2Q@100') construction to the following:
nd
10.Static water level below top of casing: N D (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 (ill.) 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) -7 Method of test:Blow 24c.For Water Supply& Infection 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: rU 1/."°- 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