GW1-2021-00368_Well Construction - GW1_20210315

WELL CONSTRUCTION RECORD (GW-1_1 f For Internal Use Only:
1.Well Contractor Information: F,(L,e-
0 1A6C1,0- 14.WATER O DESCRIPTION
Well Contractor Name FROM/r!
ft. G O tsl�v
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable
James Darby Well Drilling, LLC FROM To DIAMETER THICKNESS MATERIAL
Company Name V ft. (Sl9L'ft. b
o in. TJL2\ I fe/z,
13244 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.UIC,County,State,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 DMunicipaVPublic 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) x)Residential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft a C7 fL
Monitoring [DRecovery ft. ft
Injection Well:
ft. ft
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. it
Experimental Technology DSubsidence Control ft. ft
8 Geothermal(Closed Loop) DTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soittrock type,grain size,etc
ft. 14
ft.
4.Date Well(s)Completed: Well ID# ft , 1 ft- S
5a.Well Location: �ft• Ll(D • rm'l. /"W l
Christopher Johnson yJ W�i1 ✓Lo-r-�.
Facility/Owner Name Facility MM(if applicable) -/;l-ft. ft.
1035 Riddle Rd.Gastonia, NC 28056 ft. ft. v
tvs � m � riy
Physical Address,City,and Zip ft. ft. �., *' I i• es
Gaston 21.REMARKS
NI AR
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: „��; „^
(if well field,one hit/long is sufficient) 22.Certification Q u' v2 f01�
� o
N W
6.Is(are)the well(s)E)Permanent or ❑ITemporary Signature of Certified Well Con actor 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: DYes or X)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 I GW-I 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: 0Ct (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: (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 A (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) L 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: ( completion of well construction to the county health de artment of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources �� Revised 2-22-2016