GW1-2022-00206_Well Construction - GW1_20221216

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
2- 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
-3 3I it.
.;6 it.
ft. 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 MATERIAL
ft. a,� IL
l4 4 in. H
Company Name I
16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. is
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM I TO I DIAMETER I SLOT SIZE I THICKNESS I MATERIAL
I Agricultural DMunicipal/Public ft. ft. in-
I Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
I Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
I Irrigation ' FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: D it. ft %p
I Monitoring Recovery ft. ft. r
Injection Well:
ft. ft. ;
I Aquifer Recharge Groundwater Remediation
_ 19.SAND/GRAVEL PACK if applicable)
I Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
I Aquifer Test OStormwater Drainage ft. ft.
I Experimental Technology Subsidence Control ft. ft.
I Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
_
I Geothermal(Heating/Cooling Return)
- 1 ZOther(explain under#21 Remarks) 0 ft. it.
FROM TO DESCRIPTIONolor,hardness,soil/rock type,grain size,etc.
4.Date Well(s)Completed:�� '�l9 '-Well ID# (t ft. ft. --t?kjgy� zc/ff
5a.Well Location: fa ft. it
Ever Cruz r`• ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft r g ?- p P,�'u
2903 Forbes Road, Gastonia, NC 28056 ft. ft. = t
Physical Address,City,and Zip ft. ft. f1 r C ! 1
Gaston 21.REMARKS J
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 !:tl-f-ice
6.Is(are)the wells) O Permanent or DTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certj�that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [DYes or MNo with 15A NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known ivell 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 thisform.
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: f SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �7 5 (fk) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dijjerent(example-3@200'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 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.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) ��U 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: AV,- 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