GW1-2021-03651_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Conti etor Information:
Sj`l I Sr e-rL 14.WATER"ZONES
FROM TO DESCRIPTION
Well Contractor Name
s�r�• .-iy ft. s
' KS (//�
NC Well Contractor Certification Number 15.OUTER CASING(foe:multi-case&Wells OR LINER if a licable
James Darby Well Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
D ft. p ft. / in. ih r P,A.d
Company Name 3502 tv IC V
16.INNER CASING OR TUBIN eothermal closed-loo" "
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
1,ist all applicable well construction permits(i.e. WC,County,Stale, 1ariance,etc) ft. ft. in.
3.Well Use(check well use): ft. L in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural Municipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) xResidential Water Supply(single) in.
Industrial/Commercial OResidential Water Supply(shared) is.GROUT
FROM TO _ MATERIAL Irrigation � L EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. { ft. f�l D
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK:if a 7icable
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage
ft. ft.
Experimental Technology Subsidence Control
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additlorial sheets i€necessa
._.. FROM TO DESCRIPTION color,hardness,soiltrock type, rain size,etc.)
Geothermal(Heating/Cooling Return) ,�!rO�ther(explain under#21 Remarks) Q 0-1
��
4.Date Well(s)Completed: /t7 GL AVell ID# ft- 906
ft, a kYA-
ft. ft.
5a.Well Location:
Tim Conner
Facility/Owner Name Facility ID4(ifapplicable) ft. ft. , f►O \
3200 Beaty Road, Gastonia 28056 ft. ft. l• �� �
Physical Address,City,and Zip ft.
Gaston
21.REMARKS n %
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one IatAong is sufficient) 2VC,,
lion
N W
6.Is(are)the well(s) x Permanent or OTemporary SiLnature ofCedified W51ICdntractoi /. Date
� Hy signing this form, I hereby cerli&that the well(%)was(were)constructed in accotclance
7.Is this a repair to an existing well: Oyes or [9No with 15A NCAC 02C.0/00 or 15A NCAC 02C.0200 Well Construction Standarciv and that a
It this is a repair,fill ant known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under.;2l remarks.section or on the hack of this torn!.
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-I 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: 9 �O (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Iv)r multiple wells list all depths t/chl Brent(example-3(t�i 200'and 2 a/Oft) CODStrUCtiOn l0 the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
//water level is above caving,use", ' ' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For Injection Wells: In addition to sending the form to the address in 24a
r 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: tt 1636 Mail Service Cee!nter,Raleigh,NC 27699-1636
13a.Yield(gpm) 0 Method of test: OW 24c. For Water Supply& Iniectio&Wells: In addition to sending the form to
p the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: RTI+ Amount: I O DZ completion of well construction to the county health department of the county
where constructed.
Fonn GW-1 North Carolina Department of Environmental Quality-Division of Water Resources; Revised 2-22-2016