GW1-2021-02300_Well Construction - GW1_20210527

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: " f
�AL.TC A 14ks 14.WATER ZONES
Well Contra Name FROM TO DESCRIP'['[ON
Contractor
��&2 s A ft. �'ft. � tK.
O ft, ft ,5
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased (IR LINER if ap livable
James Darby Well Drilling, LLC FROM TO DIAMETER THICKNESS MATERIAL
Company Name 13388
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. fL in.
3.Well Use(check well use): ft. fL in.
Water Supply Well: 17.SCREEN
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
J Agricultural [3Municipat/Public ft. ft. in.
J Geothermal(Heating/Cooling Supply) x)Residential Water Supply(single) ft g, in.
I Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
TO MATERIAL EMPLACEMENT METHOD&AMOUNT
J Irrigation FROM
Non-Water Supply Well: D
ft. 1,6
0
ft.
I Monitoring EIRecovery ft. ft.
Injection Well: ft fL
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
I Aquifer Storage and Recovery E)Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OJ Stormwater Drainage ft. ft
1 Experimental Technology 0 Subsidence Control ft. fL
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) J Other(explain under#21 Remarks) FROM ft. To ft. DESCRIPTION color,hardness,soWrock type,grain size,etc
4.Date Well(s)Completed: Well ID# ft. ft.
fL fr.
5a.Well Location:
Justin Davis ft. I ft.
Facihty/Owner Name Facility ID#(if applicable) & ft. i a.
3119 Channel View Landing Belmont, NC 28012
Physical Address,City,and Zip ft. ft. y
Gaston 21.REMARKS v
Inun,-,aMn r
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IaUlong is sufficient) 22.Certification:
N W fix, 4-a
6.Is(are)the well(s)oPermanent or OTemporary Si are of Certified Well Contractor, Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OJ Yes or J No with 15A NCAC 02C.0100 or I5A 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 details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: , SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 14 (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 Iniection 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) 2� Method of test:Blow 24c.For Water SuuDly&Iniection 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: 7 6Z.. completion of well construction(to the county health department of the county
where constructed.
E
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016