GW1-2021-03661_Well Construction - GW1_20210823

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WELL CONSTRUCTION RECORD (GW-1) ,For Internal Use Only:
1.Well Contractor Information: j
14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name /p 4 ft. I 31 A D� k. 'j ��g ft. ft S1 W fv\-
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LINER if a livable
James Darby Well Drilling, LLC FROM To DIAMETER THICKNESS MATERIAL
O k U eN ft t 'in. V rfi
Company Name 13406 `
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. ft. in.
Y.
3.Well Use(check well use): ft. ft In.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
1 Agricultural [3Municipal/Public 0 ft ft. in:
_ Geothermal(Heating/Cooling Supply) xE Residential Water Supply(single) ft g• in:
:]Industrial/Commercial DResidential Water Supply(shared) i8.GROUT
J Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. �+
i Monitoring ®Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
I Aquifer Storage and Recovery Barrie[ FROM TO MATERIAL EMPLACEMENT METHOD
_I Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology [3 Subsidence Control ft• k•
i
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
I Geothermal(Heating/Cooling Return) rJOther(explain under#21 Remarks) FROM TO DESCRD'TION color,hardness,soWrock in size,eta
Q ft. /22. C
4.Date Well(s)Completed: r V't' 7A Well ID# ' ft ft.
5a.Well Location: k ft. ti AN VJM*' go C
Glover, William go c- +
Facility/Owner Name Facility ID#(if applicable) ft• ft e t A
400 Bethany Rd. Gastonia, NC 28052 ft. ft. e�` q
Physical Address,City,and Zip ft. ft. ' L
Gaston 21.REMARKS
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.Certification:
N W
6.Is(are)the well(s) XJ Permanent or OTemporary Signature of Certified Well Contractor 1. 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: E3Yes or XI 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 Idthe 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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also�attach additional pages if necessary.
drilled: l SUBMITTAL INSTRUCTIONS i
9.Total well depth below land surface: a� (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 1@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
11.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
B t
13a.Yield(gpm) � Method of test• low 24c.For Water SuoDly&Iniectiori 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: / Ul/ 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
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