GW1-2022-00207_Well Construction - GW1_20221216

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:L.at/+�� :� (
Jta 1 S l/l.a\
14.WATER ZONES
Well Contractor Nam v I 2 FROM ft TqO ft. DESCRIPTION
2 A J`�nll ft. ft. Y
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
Company Name
ft. ft 1
1(,I.in. S 1�l IR'L C.
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: I FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.a UIC,County,State,Variance,etc.) ft. tt in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROM REE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
I Agricultural DMunicipal/Publie ft. ft. in.
I Geothermal(Heating/Cooling Supply) gResidential Water Supply(single) ft. ft.
I Industrial/Commercial DI Residential Water Supply(shared) —I"ROUT
I Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: it. fL i _ r
I Monitoring DRecovery ft. ft
Injection Well:
_ ft. ft.
I Aquifer Recharge Groundwater Remediation
_ 19.SAND/GRAVEL PACK(if applicable)
I Aquifer Storage and Recovery DI Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
I Aquifer Test DStormwater Drainage ft.
I Experimental Technology nSubsidence Control ft. ft.
I Geothermal(Closed Loop) DTracer 20.DRILLING LOG attach additional sheets if necessary)
__ FROM TO DESCRIPTION color,hardness,soil/rack e, rain sim,etc.
I Geothermal(Heating/Cooling Return) I Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed: (6- -22 Well ID# ft. ft.
5a.Well Location: ft, ft. _
Tripp White ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. D E C I
r No#yet Cherryville Hwy., Cherryville NC 28021
ft. ft.
Physical Address,City,and Zip
Gaston 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is.sufficient) 22.Certification:
N W
6.Is(are)the well(s)OPermanent or Temporary Signature o rtified Well Contractor Date
� By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [DYes or 1_4No 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#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
9.Total well depth below land surface: Lon (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@200'and 2@I00) construction to the following:
10.Static water level below top of casing: �Z- (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 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) Method of test: blow 24c.For Water Supply&Injection 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: completion of well construction,to the county health department of the county
where constructed.
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resour i es; Revised 2-22-2016