GW1-2021-07827_Well Construction - GW1_20211102

WELL CONSTRUCTION RECORD (GW=fi, O `1=or Internal Use Only:
1.Well Contractor Information: ��\{ P• '� r\ : ��
je-4 —se-1--zee �,: `:-;, ,1 .WATER ZONES
Well Contractor Name .,.^:�= .:, -FROM TO DESCRIPTION
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
James Darby Well Drilling, LLC FROM TO DI%METER THICKNESS MATERIAL
6 ft. ' ft. p e �/I
Company Name 13415 sS lo
16.INNER CASING (geothermal closed-too
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL.
l.nt all apphcahle rvt-ll consh•uction pet•mth.v(i.t-. lli('.(oun(ta.State. bariance.erc) ft. ft. in.
3.Well Use(check well use): fr. ft. in.
Water Supply Well: 17.SCREEN
ppy FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL,
Agricultural Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) x]Residential Water Supply(single) ft. rt. in.
Industrial/Commercial DResidential Water Supply(shared) t8.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. ® ft. IC v Rou-Vlay6ae
Monitoring Recovery
Injection Well:
fr. fr.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) QlTracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type, rain size,etc.
Geothermal(Healing/Cooling Return) 'Other(explain under 421 Remarks) rt. b ft. ci /J/
C o
4.Date Well(s)Completed: _ d Well ID# ft. I q ft. , h /�
rr. ft. �,�� N Sa.Well Location:
Stan Pressley ft* ft. 4"
Facility/Owner Name Facility lD#(ifapplicable) 0 ft. / ,6 ft' jiN 1koell
202 Crawford Rd. Gastonia, NC 28052 -72 ft6 nm,,a Cr
Physical Address,City,and Zip fr. I ft.
C�s 21.REMARKS
County 6 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) x Permanent or Temporary Sign. a Certified Well Col aolor Date
lit+signing this%arm. l herehv cerlifi-that the well(v)was(Here)constructer/in accordance
7.Is this a repair to an existing well: Oves or 9No with I5A NCAC 02C.0100 ar l iA NCAC 02C.0200 Well('oiistrtrclion.4landat•(I.v and than a
l//his is a repair.till out known well consintclion information and erpluin the nature of the copy of this record has been provided to the well owner.
repair t(ncler 21 renta ks seclion or on the buck of lhi.c form. 1
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
ho r multiple wells list a//depths ldlferenl(erample-3@1200'and 2(@100') Construction to the following:
10.Static water level below top of casing: ? (ft.) Division of Water Resources,Information Processing Unit,
//'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,IUnderground 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 Supply& Inieciion Wells: In addition to sending the form to
the address(es) above, also submit one copy of this forni within 30 days of
13b.Disinfection type: HTH Amount: OZ completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016