GW1-2021-02321_Well Construction - GW1_20210527

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: _
14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Wine
.1. 2S ft. O ft.
`�01 ��ft. zSS ft. (Q tM
NC Well Contractor Certification Number 15.OUTER CASING for I iulti-"Yedwells OR LINER if a livable
James Darby Well Drilling LLC FROM To DIAMETER THICKNESS MATERIAL
Company Name ft. c�� ft. in. 11bRLk ?qC
13350 16.INNER CASING OR 1 UBINGl/(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
It Agricultural OMunicipal/Public 0 ft. ft. in.
:,)Geothermal(Heating/Cooling Supply) EiResidential Water Supply(single) ft. ft. in•
IndustriaUCommercial D1 Residential Water Supply(shared) 18.GROUT
Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: (� n• 2'o ft. ba-AVAC
S
31.Monitoring 13Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DJ Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
I Geothermal(Heating/Cooling Return) J Other(explain under#21 Remarks) FROM
ft. ft.To DESCRIPTION color,hardness,soil/rock rain size,eta
4.Date Well(s)Completed: �� 1�2� Well ID# (�`i S� ft. ft.
5a.Well Location: ft. ft.
Cornerstone III Prop. ft. ft.
Facility/Owner Name Facility ID#(if applicable) h' ft. p•piei.
�.
106 Crawford Road, Gastonia, NC 28056 ft. ft. �'�
Physical Address,City,and Zip ft. ft. r 021
Gaston 21.REMARKS
County Parcel Identification No.(PIN) rC{
nrS1B; ,Ir
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: i
(ifwell field,one tat/long is sufficient) 22.Certification:
N W J_
1-0-2 f
6.Is(are)the wells)oPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or w No with ISA NCAC 02C.0100 or ISA 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 if different(example-3@200'and2@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: j
(i.e.auger,rotary,cable,direct push,etc.) i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-16M
13a.Yield(gpm) 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: In CS'L 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