GW1--03371_Well Construction - GW1_20230517

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WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information: i
sq-il-n Ie Z le 2 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
02 1 51.5 y�a�/73 ft. ft.
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
Oft. -10 ft. ¢ in svrz-2 i I Pve.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
13759
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS 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.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E]Municipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: (� ft �- ft (C ft U Lr a
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery E3Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test QI Stormwater 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,soilfrock e, rain size,etc.
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) d ft. ` ft. `t '
4.Date Well(s)Completed: ?%Z 3 Well ID# 19 ft ft. &a w
5a.Well Location: Ll q ft y(P ft.
Rod d tM
Grant Gildehaus q 11 ft 7&0 ft a rz'1q"' ?t
Facility/Owner Name Facility ID#(if applicable) ft. ft.
131 Brook Crossing Dr. Mt. Holly, NC 28120 ft. ft. .;
Physical Address,City,and Zip ft. ft +�. -•' --ti �` Y^^
Gaston 21.REMARKS ►I �/
I L •I
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latdong is sufficient) 22.Certi cation:
N
6.Is(are)the well(s)EIPermanent or OTemporary Signaftfot Certified WA 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: []Yes 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#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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 76 o (fk) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths it different(example-3@200'and 2@I00') construction to the following:
10.Static water level below top of casing: 3 7, (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 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 SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) /? Method of test BOW 24c.For Water Supply&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: -7- 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