GW1--05295_Well Construction - GW1_20230814

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
5 414-11 ber 1<L ..S 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name q
O r A e is .e-t( &/2.1/ 1.71 ft. l Z rL ft. I5 1 y4
2p.a
0 1otl ft. a l ft. a ,.10 /o Itier`',„
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
James Darby Well Drilling, LLC FROM TO DIAMETER THICKNESS MATERIAL
oft. 1 SCr ft. lor in. S Dit� &I.2„( Pt
Company Name
14019 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.) ft. ft. in•
3.Well Use(check well use): ft ft. in.
17.SC
Water Supply Well: FROM REEN TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Va
Agricultural DMunicipal/Public I loi $rt. 175 ft. 4 in. 0 $e(._t_toGeothermal(Heating/Cooling Supply) (Residential Water Supply(single) ft. ft. in.
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
- Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. a,o ft. yule. 'PI u1 e0 v-K 3 a, kV
Monitoring DRccovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge 0 Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery ❑I Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test IJStormwater Drainage ft. ft.
Experimental Technology 0 Subsidence Control ft. ft.
Geothermal(Closed Loop) jTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) [Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soil/rock type amain size etc.)
ry * ft' ti 3. ft. 54 Fr- R.4. 61,47
4.Date Well(s)Completed:5.2S-0 3We lliD# �1,/' 5 ft. 100 ft. s0FT' B0..d.,it-Cstl47
5a.Well Location: I O0 ft. /3v ft. 1Qrto w . e Iratt 1 Sit c4,
Maria Salto /30 ft. /5 f° L acts le
Facility/Owner Name Facility 1D#(if applicable) 1 .551 ft- 303 ft- C airy d I Re,l ..so Pr srgf
210 Mays Rd. Dallas, NC 28034 ft. ft.
ft. ft.
Physical Address,City,and Zip F`"" u;, aA ."I. B 71
Gaston 21.REMARKS ti \1....'t,./L--i ' a---"�
County Parcel Identification No.(PIN) A U G 1 Z. 2 C 23
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.CertitI tion: M itii"'`'1n Pr^-2�"4,'c`)Ur'
- } r,`
DWZJ;'tea
N W hi,e-- ' , apt L 0.23
6.Is are the well(s) rX Permanent or I Temporary Signa re o Certified Well Cactor ,`j 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: [JYes or [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#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: 3 0 3 (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: 6 2- (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
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) (p 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
13b.Disinfection type: HTH Amount: 6, PS- 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