GW1-2021-02309_Well Construction - GW1_20210527

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
(L"rV1lt. s Is/2)
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3tss a � Mft- 9W�
NC Well Contractor Certification Number 15.OUTER CASING for multi-eased wells OR LINER ifs licable
James Darby Well Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
ft ft. I t' in. �1'1 1 P V�
Company Name 13449 V
16.INNER CASING OR TUBING eothermal 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. im
3.Well Use(check well use): ft ft in.
Water Supply Well: FROMREE TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural [3Municipal/Public ft. fL in.
Geothermal(Heating/Cooling Supply) J Residential Water Supply(single) ft. ft, in.
Industrial/Commercial 13Residential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. ft. kJ' 6,�_te 'L
31 Monitoring 13Recovery ft. fL
Injection Well: ft. ft.
Aquifer Recharge 13Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
3I Aquifer Test 1J Stormwater Drainage ft. ft
I Experimental Technology Subsidence Control ft. fL
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheetsif necessary)
Geothermal(Heating/Cooling Return) EJOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soWrock tyM grain size,eta
0 ft. ft.
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4.Date Well(s)Completed:-J-7'�) Well ID# ft' ft'
5a.Well Location: ft ft O
Cliff and Elsie Custer Ib f` a & e,, F-c-L
Facility/Owner Name Facility ID#(if applicable) ft' al(S__fL C
5180 Kings Pinnacle Dr., Kings Mtn. NC 28086 ft. ft. q,
Physical Address,City,and Zip
ft. ft.
Gaston 21.REMARKS
County Parcel Identification No.(PIN)
r� nnrac$1II�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I w,unattn r c v
(if well field,one lat/long is sufficient) 22.Ce M cation:
N W
6.Is(are)the well(s)oPermanent or ©Il Temporary Signature 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: Oyes or Xt 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 421 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
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9.Total well depth below land surface: J 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 1@100) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: ob (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
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) / Method of test: V it`'J 24c.For Water Supply&Infection Wells: In addition to sending the form to
4 the address(es) above, also submit'one copy of this form within 30 days of
13b.Disinfection type: a I ` ' Amount: ho oL 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 Resource`s Revised 2-22-2016