GW1-2022-03084_Well Construction - GW1_20220307

a-i n n r vi i ri—
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.We�ntracto Information: /Z2
Q r Pj 14.WATER ZONES
Well Contt acttoo /Name FROM TO DESCRIPTION
�n( J ti O191,
ft. I tt
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 TMCKNES/S MATERIAL
6 ft. r ft cin. ( G
Company Name 6— , ✓✓
q c p 16.INNER CASING OR TUBING(geothermal closed-loop)
136v
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) IL fL in.
3.Well Use(check well use): tt. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 1J Municipal/Public ft. ft. 1 m. _610
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. it in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
__11Irrigation FROM TO MATERIAL E LACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft O ft. U
j Monitoring E3Rccovery ft. ft.
Injection Well:
ft ft.
J Aquifer Recharge nGroundwater Remediation 19.SAND/GRAVEL PACK ifapplicable)
D Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test C)Stormwater Drainage ft ft.
I Experimental Technology Subsidence Control it. it.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) 3Other(explain under#21 Remarks) FROM ft. TO DESCRIPONcolor,hardness,soil/rock type, rain size,etc.
ft. Red S 0,
4.Date Well(s)Completed: ahoL Well ID# ft. ft �n �/
5a.Well Location: ft. ft
Timmy Almond ft rt ` i
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
315 W. Westview Rd., Gastonia NC 28052 ft. ft.
Physical Address,City,and Zip ft. ft.
Gaston 21.REMARKS
ov G o
County Parcel Identification No.(PIN) V r�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: MAR 0 I
(if well field,one lat/long is sufficient) 22.Certifi ation: OMA
N W illilir'��t�
6.Is(are)the well(s)MR Permanent or OTemporary Sitigznfing
eof rti ContractorD e
y this form,1 hereby c rli that the well(s)was(were)constructed in accordance .
7.Is this a repair to an existing well Yes or �No with ISA NCAC 02C.0100 or 1 CAC 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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: —(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 2@1001 construction to the following:
10.Static water level below top of casing: Lt (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 1/2 (in.) 24b.For Iniection 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) QQ 010 Method of test: blow 24c.For Water Supply&Iniection 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: completion of well construction io'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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