GW1-2021-07828_Well Construction - GW1_20211102

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: t7�)0
5+4yl (g:�J 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
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
Company Name L in. 5z) P 0
`� 7 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: /J _5 /3 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well conshztction permits(i.e. I/W.County,Slate, lariance,etc.) ft. ft. in.
3.Well Use(check well use): `t' `t' in.
17.SCREEN
Water Supply Well: `
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public R. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. tt. in.
Industrial/Commercial ID Residential Water Supply(shared) 18,GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: A fL ,2 2 `L yd tf /V PD tJ l2
Monitoring DRecovery
Injection Well:
ft. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO T MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessa
Geothermal(Heating/Cooling Return) ;.Other(explain under#21 Remarks) FROM
R© ft �/ tt DESCRIPTION(color,hardness,soil/rock e, rain size,etc.
4.Date Well(s)Completed: '3-o10.2/ Well ID# ft. fL�
ft. tt.
5a.Well Location:
Ella Mayberry
Facility/Owner Name Facility ID#(ifapplicable)
145 Miller Drive, Gastonia NC 28056 / ft• ft. y
ft.
Physical Address,City,and Zip ,
Gaston 21.REMARKS
J .4 ..
County Parcel Identification No.(PIN) t`A
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)N W 22.Certifi Cy A
n: J/
/r_5
6.Is(are)the well(s) Permanent or OTemporary signature of Certified Welycontractor Date
Bj,signing Ihi.s/i rin, l hereby-cerli&that the we/I(s)was(were)conslrucled in accordance
7.Is this a repair to an existing well: Oyes or x No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Slandards and that a
l/7his is a repair,Jill out known well construction inJnrmalion and explain the nature of the copy q/'this record has been provided to the well owner.
repair under 21 remarks section or on the hack n/7his_%nrrn.
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: Ll (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
hor mulliple wells list all depths if dillerent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: -24 (ft.) Division of Water Resources,Information Processing Unit,
/fwaler level is above casing,use" ' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 1/4 (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
13a.Yield(gpm) Method of test:blow 24c. For Water Supply& Mice tion 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: 07- 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
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