GW1-2022-00205_Well Construction - GW1_20221216

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information:
e / �` 14.WATER ZONES
PAJ A FROM TO DESCRIPTION
Well Contractor Namet L
ft A 11L LJL.f 44
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 MATERIAL
b ft' 1" 6 in. 5V k Pa ::J
Company Name
� 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: `7 Ip FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,Couno?,State,.Variance,etc.) ft ft, in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E)Municipal/Public ft. ft. in,
Geothermal(Heating/Cooling Supply) X Residential Water Supply(single) ft. ft. in.
Industrial/Commercial I3Residential Water'Supply(shared), 18.GROUT
—)irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft, 6 IL Bes• '� PCv R
Monitoring E3Recovery _ It. IL
Injection Well: ft. It•
Aquifer Recharge OGroundwater Remediation '
19.SAND/GRAVEL PACK(if a lirnble)
Aquifer Storage and Recovery DS41inity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test IOStormwater Drainage, ft. ft.
.. Experimental Technology OSubsidence Control
Geothermal(Closed Loop) [Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) MOiber(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,solltrock type.grain sr etc
Ig ft. ft. Q �.
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4.Date Well(s)Completed: Well ID# r it-
t sn fL
5a.Well Location: ft' O o ft' tl►R�'I•'S0 Rti4 ni 7 Qr
Johnny Truett f° ft'
Facility/OwnerNamc Facility ID# ifa licable ft. ft.
800 Abel Rd., Bessemer City NC 28016 ft. ft,
Physical Address,City,and Zip ft. ft. —
Gaston 21.REMARKS l nil
County Parcel Identification No.(PIN)
J\^ett�Ia�W
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lattlong is sufficient) 22.Cert •0 7
N W
6.Is(are)the weil(s)0 Permanent or [DTemporary Signature of Certified Well on c r' Date
By signing this form,I hereby certify,that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or X)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 11 to the well owner.
repair under#21 remark&section or on the back of this form.
23.Site diagram or additional well details:
You may use the back of this page.to provide additional well site details or well
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
constriction details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth-below land surface: 6 d (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(exam 3@200'�and 2@l00) construction to the following:
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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 276994617
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 of,this form within 30 days of completion of well
12.Well construction method: construction to the following: I
(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 Suably&Ini ' tioil 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 6Z completion of well construction' to the county health dep�iment of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Reso es Revised 2-22-2016
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