GW1-2021-03659_Well Construction - GW1_20210823

WELL CONSTRUCTION CONSTRUCTION RECORD (GW-1) For Internal Use Only:
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1.Well Contractor Information:
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14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
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ft.ft. ft.NC Well Contractor Certification Number t
15.OUTER CASING for multi-cased wells OR LINER if a licable
James Darby Well Drilling LLC FROM To DIAMETER TLIICLINESS MATERIAL.
O ft ft G, in.
Company Name
16.INNER CASING OR TUBING(geothermal dosed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) fL in.
3.Well Use(check well use): ft. fL In.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLAT SIZE THICKNESS MATERIAL.
-IlAgricultural [Municipal/Public 0 ft, ft. in.
Geothermal(Heating/Cooling Supply) B Residential Water Supply(single) fL ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irri ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: d ft. U fL le- Plu Po./Z
I Monitoring Recovery ft. H.
Injection Well:
ft. ft.
I Aquifer Recharge [:)Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
I Aquifer Test DStormwater Drainage ft. ft.
1 Experimental Technology 0Subsidence Control ft. fL
1 Geothermal(Closed LOOP) ©ITracer 20.DRILLING LOG attach additional sheets if necessary)
I Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soatroek type,grain ske,etc
7•�7 r1 toft• 1/0 ` ft- iZu w /4-
4.Date Well(s)Completed:(P Q% G�W//Well ID# (7 ft. ?O ft. e'�ww
5a.Well Location: ft- /SS+ fL �$
Terry Whitesides ft. j &2ft-
Facility/Owner Name Facility ID#(if applicable) ft• ft.
1225 Old Providence Rd. Gastonia NC 28052 ft. ft.
Physical Address,City,and Zip ft. ft.
Gaston 21.REMARKS
County Parcel Identification No.(PIN) Pr',
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Cc ' do
N W
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6.Is(are)the well(s) XI Permanent or OTemporary Sig6harre of Certified We 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: []Yes Or XI NO with 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature ofthe 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
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9.Total well depth below land surface: .5 lJ .;�_ (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,rise"+L 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
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: 6W 24c.For Water Supply&Injection 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: / Amount: 1 A 0 Z completion of well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016
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