GW1-2021-00370_Well Construction - GW1_20210315

WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well Contractor Informationl: �G�
(� t 2a LI 14.WATER ZONES
FROM TO DFSCRIMON
Well Contractor Name nn ,+
��� �T� ft. 32u ft.
ft. 7 VS
ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a liceble
James Darby Well Drilling, LLC FROM TO DIAMETER THICKNESS MATERIAL
Company Name
6 ft SZ) f I P IlC,
13207
16.INNER CASING OR TUBING eothermal closed-too
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC,County,State,Variance,etc.) ft• ft. in.
3.Well Use(check well use): ft. It. in.
Water Supply Well: FROMCREE TO DIAMETER SLOT SIZE THICKNESS MATERIAL,
Agricultural QMunicipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) fL ft. in,
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 6 fL 20 & &u
Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL, I EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology DSubsidence Control ft. ft
RGeothermal(Closed Loop) DTraCeT 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) FlOther(explain under#21 Remarks) FROM I TO DESCRHPTION color,hardness,soil/rock type,gnin sae,etc
D fL /d fL kOecl
4.Date Wells)Completed: Well ID# fL 8$ tt e/ld w v
5a.Well Location: f 1 fL teed 43dc�C
Stephen Vernon ?— ft. 2 ft• 14n
Facility/Owner Name Facility ID#(if applicable) It. It. a ��
159 Joe Cloninger Rd. Bessemer City, NC 28016 fL ft.
Physical Address,City,and Zip ft' ft'
Gaston 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Cer' tion:
N W /9 aaai
6.Is(are)the well(s)oPermanent or Temporary SignS of Certified W 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: (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 16 (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 WELLSONLY: 1636 Mail Service Center,Raleigh,NC 27699-16M
13a.Yield(gpm) J) 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' /6 6 z— completion of well construction to the county health dep ent of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016