GW1-2022-04318_Well Construction - GW1_20220502

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
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14.WATER ZONES f
Well Contractor Name FROM TO DESCRIPTION
ft. y9
3�3 t�2Z ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased;wells OR LINER if a livable
James Darby Well Drilling, LLC FROM TO DIAMETER THICKNESS MATERIAL
D ft. ft /�'�S i
Company Name 10
13387 pvt
16.INNER CASING OR TUBING eothet mat closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) 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 E)Municipal/Public ft. it. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial E3Residential Water Supply(shared)
18.GROUT
71 Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft.
Monitoring DRecovery 0 ft. v ft. Pow
Injection Well:
ft. ft
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test C)Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) [3Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Mother(explain under#21 Remarks) FROM TO DESCRIPTION eolor,hardness,soil/rock type,grain size,etc.)
ft- _r ft C�t
4.Date Well(s)Completed: Well ID# ft / tt /tT4llZv Gj
5a.Well Location: ft' ft h/
Stephen Riley b ft ft d4
Facility/Owner Name Facility m#(if applicable) ft. ft
4509 Belhaven Forest Dr. Gastonia, NC 28056 ft. ft.
Physical Address,City,and Zip
Gaston 21.REMARKS °
County Parcel Identification No.(PIN) 7
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]aUlong is sufficient) 22.Cc r' cation' �
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N W
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6.Is(are)the well(s)>�Permanent or Temporary Si atur f Ce ' d ell ontractor D e
y signing this form,1 h eby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 13Yes `'or,E)No 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 421 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 I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS''
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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(a,260'and 2@1001 construction to the following:
10.Static water level below top of casing: (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 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,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) Method of test: Blow 24c.For Water Supply&Iniection Wells: In addition to sending the form to
ff the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: /e< d 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