GW1-2022-04319_Well Construction - GW1_20220502

WELL CONSTRUCTION RECORD GW For Internal Use Only:
1.Well Contractor Information: �y4
o e i3q ,e -J 1 /Z Z 14.WATER ZONES I
Well Contractor
_am FROM TO DESCRIP110N
l ft. �y fL �• .� vrc ��
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER tf a 6cable
James Darby Well Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
Company Name &P ft. /' ft 6 in. ;T P- { tO V6-1
16.INNER CASING OR TUBING eothermaI closed-loop)
2.Well Construction Permit#- b FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC County.State, Variance,etc.) f4 ft. in.
3.Well Use(check well use): ft. ft. in.
17.Water Supply Well: FROM SCREEN O DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public fL % in.
Geothermal(Heating/Cooling Supply) jC Residential Water Supply(single) ft. ft. in.
Industrial/Commercial D Residential Water Supply(shared) 1&GROUT
Irrigation FROM TO MATERIAI. EMPLACEMENT METHO/D�&AMOUNT
Non-Water Supply Well: fL CQ O ft-
Monitoring QRecovery
Injection Well:
ft ft.
Aquifer Recharge DGroundwater Remediation
_ 19.SAND/GRAVEL PACK(if applivable
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology Dsubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) FlOther(explain under#21 Remarks) FROM I TO DESCRIPTION(color,hardness,soiltrock type,grain size,etc.)
O ft. fL
4.Date Well(s)Completed: Well ID#13606 ft. ft-
fied Om 0.
5a.Well Location: ' ft 0 ft A /
Steve Brown O ft- 9.v ft.
Facility/Owner Name Facility ID#(if applicable) ft. /Q -- Cad
0�
140 Circle B Farm Rd., Kings Mountain, NC 28086 tb ft. 1 ft. 'Roe,
Physical Address,City,and Zip ft. ft.
Gaston 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Y O
(ifwell field,one]at/long is sufficient) 22.Certification:
DO
N 4 � �
W I,.7 t`,"PAX I '
6.Is(are)the well(s) Permanent or Temporary 4k
Sign re ofC ified Contract Date
B signing this form,1 hereby c ify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or ®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 4f 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 Geotbermal 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: 1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: op (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example- @200'and 2@a 1001 construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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) V Method of test: blow 24c.For Water Suably&Infection 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: !J 0 completion of well construction;io the county health department of the county
where constructed.
Form GWA North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016