GW1--03358_Well Construction - GW1_20230517

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
��p'►�� ��/ �� 14.WATER ZONES
Well Contractor Name --�, _/ FROM TO DESCRIMON
►! ft. j l `DFA.) S-f 04
t3�3� 1 ft i L. P wti
NC Well Contractor Certification Number 15.0 TER CASING for multi cased wells OR LINER if a licable
James Darby Well Drilling, LLC FROM TO DIAMETER T111004ESS MATERIAL
Company Name o ft. 1103 It. &� rn ng.Z 1tko vs-
13953 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,State,Variance,etc.) (b ft ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICK MESS MATERIAL
Agricultural [:)Municipal/Public 0 ft ft. in- k`t eC
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM I TO MATFRUL EMPLACEMENTT AWMOD&AMOUNT
Non-Water Supply Well: b ft �,Zft• //a/c �d o Ok
Monitoring Recovery ft. f� ft
Injection Well:
ft ft
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)_
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
-Aquifer Test OStormwater Drainage ft ft
-Experimental Technology E3Subsidence Control ft. ft.
Geothermal(Closed Loop) DTracer 20.DRILLING LOG attach additional sheets if necessary)
_ _ FROM TO DESCRIPTION color,hardness,soil/rock e, rain size,etc
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) D ft 2 ft. fz l��
U-
4.Date Well(s)Completed: el ID# ;L Z ft S I ft e0(p tv
5a.Well Location: .51 79
Clarkston Hines 9 rr ft. 00 ft-
Facility/Owner Name Facility ID#(if applicable) ft. ft
457 Airport Rd. Gastonia, NC 28056 ft ft 1;���" -�
Physical Address,City,and Zip ft. ft \
Gaston 21.REMARKS 1 L
County Parcel Identification No.(PIN) �Q
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.
N W
6.Is(are)the well(s)oPermanent or OTemporary Si ofCertified WeyCo6tractor 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: OYes or JNo 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-I 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: .2196 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiereni(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,
Ifwaier level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 1 A (in.) 24b.For Injection 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 SUPPLLY�WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) O Method of test: Blow 24c.For Water Suably&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.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016