GW1-2021-07835_Well Construction - GW1_20211102

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
SPw I'4 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
$ A y5 ft. 8 t. 4 �-
fL ft.
NC Well Contractor Certification Number 15.OUTER CASING for mull-cased wells OR LINER if a licable
James Darby Well Drilling LLC FROM TO DIAMETER THICKINESS MATERUL
Company Name Q ft NN to
- ft. D Q�' E v e
/ f 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: / I FROM I TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.WC,County,State,Variance,etc.) N• ft in.
3.Well Use(check well use): ft. ft in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATF.RiAr.
Agricultural []Municipal/Public 0 ft. ft. in.'
I Geothermal(Heating/Cooling Supply) x!Residential Water Supply(single) g• ft
Industrial/Commercial DResidential Water Supply(shared)
]8.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 9) fL Q�a Po V R
rt
I Monitoring EIRecovery ft. ft.
Injection Well:
It. ft.
Aquifer Recharge O1 Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
I Aquifer Storage and Recovery DSalinity Barrier FDRILLI
TO MATERIAL EMPLACEMENT METHOD
I Aquifer Test DStormwater Drainage D
I Experimental Technology Subsidence Control ft
Geothermal(Closed Loop) Tracer NG LOG attach additional sheets if necessary)
I Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) To DESCRIPTION color,hardness soiUrock in size,eta� fL4.Date Well(s)Completed: 8 — 0— Well ID# 5O k5a.Well Location: ft*
Daniel Hall 71 Jb;t-ff 2Arn. -
4'
Facility/Owner Name Facility ID#(if applicable) ft. ft.
2691 Rufus Ratchford Rd., Gastonia NC 28056 It. ft. � ,
Physical Address,City,and Zip ft. ft.
Gaston 21.REMARKS
County Parcel Identification No.(PIN) V
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Ce 'ication:
N W (21�ZL / /o aU ram?J2 I
6.IS(dre)the well(s)opermanent or OTemporary Signature of Certified Wei Contractor Date
By signing this form,I hereby cer16 that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or IgNo 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 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
9.Total well depth below land surface: �26;L (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 7 y (ft.) Division of Water Resources,Information Processing Unit,
if water level is above casing,use"+"I 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 1e7 (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:u 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
m)
13a.Yield(gP D Method of test: n)�l.� 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: HTqAmount: / 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