GW1--03359_Well Construction - GW1_20230517

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:+Jt},t I a SP. 1-�^Ze 12 14.WATER ZONES
%
Well Contractor Name FROM TO DESCRIPTION
Lg J A �Ol�;�' 2 ft. �7.7 fi- -U,,m4,w_ � j.. 61 p m
S "�„ �3/ _ _ 3 67 ft. 34 ft• ti .5 a M
NC Well Contractor Certification Number 3/oZ 7/43 15.OUTER CASING for multi-cased wells OR LINER if a licable
James Darby Well Drilling, LLC FROM TO DIAMETER THICKNESS MATERIAL
o it: ft sarc.t PVC
Company Name 13791
16.INNER CASING OR TUBING(geothermal closed-too
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERW,
List all applicable well construction permits(i.e.UIC,County,Slate,Variance,etc.) ft. ft.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
0Agricultural []Municipal/Public 0 ft. & in.
Geothermal(Heating/Cooling Supply) (Residential Water Supply(single) ft. ft. in.
Industrial/Commercial [](Residential Water Supply(shared) 18.GROUT
Im ation FROM I TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. A I ft140 le flas 0 U
Monitoring EiRecovery ft. ft.
I ft. ft.
njection'Recharge Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
licable_
Aquifer Storage and Recovery [DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test []Stormwater Drainage ft. ft.
-Experimental Technology E3Subsidence Control ft. fL
Geothermal(Closed Loop) []Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) _ Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiltruck type rain sae,etc
D tt. t2 2, ft. -1 /f I 1�
4.Date Well(s)Completed>2'gal-,202. Well ID# o2Z ft. /f tt RG W 4
5a.Well Location: � It. 0 / ft 12i4'w C OCk 4%s*-h-il Ptl
Darryl Beach ! f` 783 f` &^- ►;+e_
Facility/Owner Name Facility ID#(if applicable) ft. fL
3103 Allison St. Belmont, NC 28012 ft. ft. �
Physical Address,City,and Zip ft. ft.
Gaston 21.REMARKS /
County Parcel Identification No.(PIN) �.I
- rj:IdQ1�� .
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Ce do y
N Wt
6.Is(are)the well(s) 'x Permanent or Temporary Si of certifie W 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: []Yes orJNo 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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: p SUBMITTAL INSTRUCTIONS
O
9.Total well depth below land surface: 3 3 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100� construction to the following:
10.Static water level below top of casing: y , (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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) ty - Method of test Blow 24c.For Water Supply&Injection Wells: In addition to sending the form to
a 0 7 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: lJ + 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