GW1-2022-00204_Well Construction - GW1_20221216

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: i
Ir� 14.WATER ZONES
Well Contractor ame / FROM TO DESCRH'TION
as�jl -� FV/ A0 s � ft. s IL
tt. It.
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 THICKNESS TEMAL
611- 11
13
ft.
t -2 in. I
Company Name
16.INNER CASING OR TUBING eolhermal closed-loop)
2.Well Construction Permit#: 310 FROM TO I DIAMETER THICKNESS I 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
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
I Agricultural E]Municipal/Public ft. ft. hi.
I Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
I Industrial/Commercial DResidential Nate;Supply,(shared)^ 18.GROUT
I Irrigation _tx,.t } E� i+ 's.1 FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: yy nnq ft. D ft.
I Monitoring DRecovery r C 1 Zl'L� ft. ft.
Injection Well:
I Aquifer Recharge �GrouQdgyatef Reri�eti`atigt�
jt;',�! L 19.SAND/GRAVEL PACK(if applicable)
I Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
I Aquifer Test E3Stormwater Drainage ft. ft.
I Experimental Technology EI Subsidence Control ft. ft.
I Geothermal(Closed hoop) Tracer 20.DRILLING LOG attach additional sheets if necessa .
FROM TO DESCRIPTI N color,hardness,soil/rock typ0.grain size,etc.
I Geothermal(Heating/Cooling Return) n Other(explain under#21 Remarks) ft. ft. Sa/
�e
4.Date Well(s)Completed: 00a) Well ID# ft. 3 ft. rDL.117 50/1
5a.Well Location: it[t 'J row -
Derek Me ft' /0 5"" r0 ,56
Facility/Owner Name Facility ID#(if applicable) d ft. ft. 1 LX /r A W e 6 1
604 Ferguson Ridge Rd., Gastonia, NC 28062 ft. 6 art. rvniT Qtl<
Physical Address,City,and Zip ft. ft.
Gaston V S3)- /Q - 3-f6 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W P
6.Is(are)the well(s) ermanent or Temporary Sigma f Cert' ed w onhactor Dat v�
By :gning this form,1 hereby certio�y t the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or 2JNo wtth 15A NCAC 02C.0100 or 15A NC 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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
� 1
9.Total well depth below land surface: ..!©a (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiferent(example-73g200'and 2®100� 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 1/4
(in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
rotary above, also submit one copy ofj 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) po Method of test, blow 24c.For Water Supply&Iniection Wells:'In addition to sending the form to
the addre,ss(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 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 Resou Ices Revised 2-22-2016