GW1-2023-02180_Well Construction - GW1_20230306

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
stG'Y\ did 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION c
7 �
4I� o2 A °1/2Z {t. ft. j
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 l
l ft. Vo ft !0 /� io. 6+.ntx`21 I p V c
_ p t��� 16.INNER CASING OR TUBING eothermal closed-loop)
2.We11.Constrnction.Permit.#:�__- - FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(1.e.-UIC,Coun),,-State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
I Agricultural ❑I Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
i Industrial/Commercial Residential Water Supply(shared) 18.GROUT
I Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q ft. /� ft. tams
I Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK If applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
—I Aquifer Test 0 Stormwater Drainage
I Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
I Geothermal(Heating/Cooling Return) F1 Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soillrock type rain size,etc.)
1 ft. ft, q
4.Date Well(s)Completed: - Z-2t, We11 ID# V ft. G ft
Sa.Well Location:
ft. Da ft.
Tyson Preston ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
301 Miles Rd. Dallas, NC 28034 ft. ft.
Physical Address,City,and Zip
ft. ft.
Gaston 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: o -,N W p1X MWK 1(47-27-
6.Is(are)the well(s) X Permanent or DTemporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or X�i No with 15A NCAC 01C.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 Geoprohe/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
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9.Total well depth below land surface: I V v (ft-) 24a. For All Wells: Submit this'form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) 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 A (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) 1 Method of test: Biota 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: 10, OZ 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 Resources Revised 2-22-2016