GW1-2022-04326_Well Construction - GW1_20220502

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WELL CONSTRUCTION RECORD t(�GWy-1) For Internal Use Only:
1.Well Contractor Information: T
14.WATER ZONES f
Well Contractor Nam — FROM TO DESCRIPTION
3A i - Aft. ft. s "
NC Well Contractor Certification Number ft. jJb ft // zwe
I5XTER CASING(for multi-cased wells)OR LINER if a licable
James Darby Well Drilling LLC FROM TO DIAMETER. THICKNESS M ERIAL
O ft It. /�0
Company Name (
y�
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#• l 3 c t Ds FROM I TO I DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC.County.State, Variance,etc) ft. fL in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [:JMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OC Residential Water Supply(single) rt ft in.
[ndustrial/Commercial Residential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMP ACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q It. d It.
Monitoring 13 Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery Salini Barrier FROM
SAND/GRAVEL PACK(Ma applicable)
ty FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [)Stotmwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPT ON(color,kardness.soillrock ty e,grain size,etc.)
ft. ft. 1UC J N(Q
4.Date Well(s)Completed: Well ID# ft. iFik
5a.Well Location: tt.
Karen Stanaland ft. t. f sPi
Facility/Owner Name Facility ID;#(if applicable) ft. 0
1517 Crowder Creek Road, Gastonia, NC 28052 1400 ir. / art.
' 4 ,
Physical Address,City,and Zip 0 ft. Wj)�ft.
Gaston z1.REMARKS 7
County parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one laUlong is sufficient) 22.Certification q q pW"�TnM�+�n
N W "�,4°r6�l lli'r'1 i�ftiY.r�a73r
6.Is(are)the well(s)oPermanent or 13Temporary Sig tore of rti ell Co for Date
B signing this.form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or EC 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 921 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: I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �2 (It.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if di/ferent(example-3@200•and 2(a)1001 construction to the following:
10.Static water level below top of casing: `f (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 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) �/' / 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: to f_ completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016