GW1-2022-03081_Well Construction - GW1_20220307

Pant Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Well Contractor Informations:
6 C` ,i IL 14:WATER ZONES
WelI Contractor ame FROM TO DESCRIPTION
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINERable
James Darby Well Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
ft. !a// ft. in.
Company Name vv - --
^� -16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit 13 ` FROM I TO I DIAMETER THICKNESS I MATERIAL
Li.si all applicable ur//cunvtrtuction/mrntits(i.e. UI•,(briinlK Slale,Variance,elc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.:-
Industrial/Commercial DResidential Water Supply(shared) 19.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: G fr. a 0 ft. e ,e Roar
:,)Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery DSalmity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStolmwater Drainage ft. ft.
Experimental Technology D Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets ifnecessa
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION(color,haidness,soilhnck type.grain sire,etc.
on-
/ ft. /�C /
4.Date Well(s)Completed: Well ID# ft. 0 fr. or" ' 9' Oi
ft. ft. Yellow / l Q/Sa.Well Location: 60
Marley Homes 5
ft. /,t7
Facility/Owner Name FacilirylD#(ifapplicable) ft.
� !/
425 Henry Chapel Rd., Belmont NC 28012 ft. ft.
Physical Address,City,and Zip ft. ft.
Gaston 21.REMARKS
County Parcel Identification No.(PIN) MA
R 07
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: lIvy y.y
(ifwell field.one lat/long is sufficient) 22.Certification:
N W44-1.17
6.Is(are)the well(s)o Permanent or OITemporary Sign. 4. .'fi,
ed well ontractor DH).igning lhis%r , /hereby certili t of the sell fs)n as(n ere)constructed in accordance
7.Is this a repair to an existing well: [3Yes or E)No a I!t ISA NCA('02C.01all or OA N(AC 02C.0200 Well Uon.struclion Standardv and Mal a
Y*lhi.s is a repair.fill out known n•ell construction iglormation and explain the nature of the copy yJ lhis record has been provided to the irell on ner.
repair under,J21 remarks section or on the hack of this 1brm.
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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: n I SUBMITTAL INSTRUCTIONS 1
9.Total well depth below land surface: /O� (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
hor mutople ire/lv list all depths i/'di(/irent(example-3G200'and 2@100') construction to the following:
10.Static water level below top of casing: J (ft.) Division of Water Resources,Information Processing Unit,
I/ualer level is ahore casing,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 1/4 (in.) 24b. For Injection 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
I
13a.Yield(gpm) Method of test: blow 24c. For Water Supply& Iniection Wells: In addition to sending the form to
Ls the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount:I / d Z completion of well construction to the county health department of the county
where constructed.
Font GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
i