GW1-2021-02299_Well Construction - GW1_20210527

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
/ t
5`- A" 1 P to �` . s ` z 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ' "y"—1
tS/l /L 1 rt. q ft el&W.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased w OR LINER if a h!Ma e
James Darby Well Drilling, LLC FROM TO DIAMETER THICKNEss MATERIAL
Company Name
© ft. _37
fL 6 L in. S 0 (1
16.INNER CASING OR TUBING eothermal closed-loop)
13366
2.Well Construction Permit#: FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft ft.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public Q ft. ft. in.
Geothermal(Heating/Cooling Supply) x�j Residential Water Supply(single) ft, ft, in,
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. Tde.
Monitoring [ Recovery ft. ft.
Injection Well: ft. ft
Aquifer Recharge 13Groundwater Remediation
19.SAND/GRAVEL PACK if a livable
1 Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft
Experimental Technology OSubsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets:if necessary)
h Geothermal(Heating/Cooling Return) F1 Other(explain under#21 Remarks) FROM I TO DESCRIPTION color,hardness,soil/rock 9yM grain size,etc
B ft ft.
4.Date Well(s)Completed: ax,Uq�tt t VcII ID# ft_ y ft.
ft ft.
5a.Well Location:
William Carter 2 rt 662-&
ft. ,
Facility/Owner Name Facility ID#(if applicable) ft. '�
739 Kiser Rd. Bessemer City, NC 28016 ft. ft.
r
Physical Address,City,and Zip ft. ft. tl
Gaston 21.REMARKS
County Parcel Identification No.(PIN) section
—71
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certiflc lion:
N W 224Lti�2L 3 J..'-,20 2
6.Is(are)the well(s) Permanent or Temporary Si re of Certifi Il Contractor Date
XI
By signing this form,1 hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: MYes or XX 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 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'and 2@I00) 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
It.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
139.Yield(gpm) -T_ 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: 12, 0-2, 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