GW1-2021-03656_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
I.Well Contractor Information: rn 6
T' VU I QiV] e`tz-e(z Ih 1 W lei 1 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
James Darby Well Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
© ft. 1 U ft. 6. I ,in. t` k q/ e V 3/S _I
Company Name ��� 1 v at Ilo Oft Gl
16.INNER CASING'OR TUBINGeothermal closed-too
2.WCII Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
Ust all applicable well constraciion permas(i.e.I//(',CounlY,Stale. biiriance,etc) ft. fL in.
3.Well Ilse(check well use): R. R. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public 0 ft. R, in
Geothermal(Heating/Cooling Supply) IgResidential Water Supply(single) rt. rt. in.
Industrial/Commercial Residential Water Supply(shared) 18,GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: © tt. r90 ft. },le ',, d! et)
le
Monitoring DRecovery
Injection Well:
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage
Experimental Technology 0SUbsidence Control
Geothermal(Closed Loop) 01'racer 20.DRILLING LOG attach additional sheets if necessary)'
FROM TO DESCRIPTION(color,hardness,soil/rock type, rain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ke,�t- e,
4.Date Well(s)Completed: 7 — ' d Well ID#
5a.Well Location: ft. l�p ft. ,�U., t f,
James Rhyne a {t. a. fLoek
Facility/Owner Name Facility IDk(ifapplicable) I 9;� ft. IL ✓ e G a
1701 Auten Rd. Gastonia, NC 28054
Physical Address,City,and Zip
Gaston 21.REMARKS
rOJ� ✓
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.Certifi-1ti' n:
N W C/J t�t,�.� �.. 7�aal
6.Is(are)the well(s) Permanent or Temporary Signaiure of Certified Wepntractor r Date
`X',
ff_v signing dhis./iu-in, I herchv cerli(b thal the well(s) was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or qNo with I.iA NCAC 02C.0100 or 15A NCA('02C.0200 N%cll Consirncliun Rmndards and thal a
I/ihi.s is a repair./ill out known well con.siruciion inliwinulion and explain the nature o/the curt:u/'dhi.v record has been provided u,'the well owner.
repair under 21 remarks section or on hhe hack q/thi.v./orm.
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 I 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: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
I-'or m lople wells list all depths i%dijjerew(example-3@200'and 2 100) construction to the following:
10.Static water level below top of casing: S3 (ft.) Division of Water Resources,Information Processing Unit,
if waier level is above caving,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) Method of test: Blow 24c. For Water Suably& Iniecti e on.Wells: In addition to sending the form to
the address(es) above. also submit one copy of this fort within 30 days of
13b.Disinfection type: H H Amount: 15 b-2— completion of well construction to the county health department of the county
where constructed. I
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016