GW1--03357_Well Construction - GW1_20230517

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WELL CONSTRUCTION RECORD (GW--1) For Internal Use Only:
1.Well Contractor Information: I- ck ,
�5+1+y ley ' e-Frz e 1R 3/t 01a3 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
l$'t5 ;q "- /�,8 ft. D/k �tIrCS�-u>Le t✓ /oZ PI1�
71 ft. I'13 fr 6'
NC Well Connector 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 6) ft. 7 g P v a
13959 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Stale,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
Agricultural E)Municipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. fr. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNr
Non-Water Supply Well: ft. t;1. ft. )46 I C Pin Po trit
Monitoring ORecovery ft. ft.
Injection Well:
_ ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)_
Aquifer Storage and Recovery [3Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology E3Subsidence Control ft. ft.
Geothermal(Closed Loop) DTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) F30ther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soillrock type rain size,eta
p f, a ft. Re.1 6A-
4.Date Well(s)Completed:2 Op-�23 Well ID# ft. 64 ft. QOw„ LI '.4
5a.Well Location: M+o ft. 72. ft. As_*ha e_.I
Pervis Baker ft I
!lJ;L ft. 2an4e-
Facility/Owner Name Facility ID#(if applicable)
ft. ft
705 Patrick Rd. Gastonia, NC 28056 ft. ft. MAY 1 7 2021
Physical Address,City,and Zip ft. ft.
Gaston 21.pRE,M,ARKS
County Parcel Identification No.(PIN) I I'�'� mat eQQltK IL�i ��
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 161 f d" `�6 f $ JL /D lis
(ifwell field,one IatAong is sufficient) 22.Cc ation:
N W
6.Is(are)the well(s)oPermanent or OTemporary Sig-narnKof Certified W Contractor 40 Date
By signing this form,I hereby cerr�that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or E)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 921 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 ifnecessary.
drilled: O SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:/O� (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
,ror multiple wells list all depths if di ferent(example-3@200'and l@100') construction to the following:
10.Static water level below top of casing: 7 (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 Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: Rotary above, also submit one copy of this form within 30 days of completion of well
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) �a 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
7 13b.Disinfection type: HTH Amount: 0 Z completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016