GW1-2022-00209_Well Construction - GW1_20221216

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
i
1.Well Contractor Information:
p S e`LIA&yS 'off I L�i'• 14.WATER ZONES
�j FROM TO DESCRIPTION
Well ContractorNante
aC ft
NC Well Contractor Certification Number `15..VOUUTTER CASI mu NG forlti ca wells OR LINER if a licable
FROM TO DIAMETER THICKNESS
MATERIAL
James Darby Well Drilling LLC
—1 ft. Jig ft. (V {�(�(�in. 2 k V C
Company Name wo,`
/ 16.INNER CASING OR TUBING(geothermal closed-loop)ES
2.Well Construction Permit#: LJ./ FROM TO DIAMETER THICKNESSS 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: FROMREE TO DIAMETER` SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipal/Public ft. ft. in.'
Geothermal(Heating/Cooling Supply) X Residential Water Supply(single) ft. ft. in
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT.
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: " 0 fG wy
__ Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL.PACK(if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothemtal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soiUrock e, in size eta
(� 9�^1 ,, ft. � ft. C
4.Date Well(s)Completed: N-(0 4-y Wel1ID# S ft. ft- G
5a.Well Location: ft. ft. �,
Mark Dellinger ft. ft. 10
ft. ft
Facility/Owner Name Facility ID#(ifapplicable) F.
2928 Tryon Courthouse Rd., Bessemer City NC 28016 it. ft.
Physical Address,City,and Zip ft. ft. r t-
Gaston 21.REMARKS r-11
County Parcel Identification No.(PIN) ry,J°�! i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
N W 6� /Q
6.Is(are)the well(s)oPermanent or Temporary Si Certi d Well Conhactor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair t0 an existing well: Dyes 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 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: f SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: IV) A) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@1000 construction to the following:
10.Static water level below top of casing: 1 (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:
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,1 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 b'L— 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,,