GW1--04427_Well Construction - GW1_20240723

ya.4e4 u(, / / / ,Y
Print Form
WELL CONSTRUCTION RECORD(GW-I) For Internal Use Only:
1.Well Contractort Information:
S- ra ledy SQ±Z.e1( 14.WATER ZONES
Well Contractor Name / FROM TO DESCRIPTION
James Darby Well Drilling, LLC / IV ft. IV ft. ..tWehii t. _ .s'
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Z / 35 A FROM TO DIAMETER THICKNESS MATERIAL
Company Name Dft. /la to 5DR-21 P IC,
2.Well Construction Permit#: t�
I, I nvvI 14 7 16.INNER CASING OR TUBING(geothermal closed-loop)
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 MAATERIAI.
gricultural DMunicipal/Public 0 it. ft in.
Geothermal(Heating/Cooling Supply) XDResidential Water Supply(single) R. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 1K GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Supply Well:
Non-Water
0 ft• a p ft- � t Pl� u, Poo 2
Monitoring Recovery ft. ft.
jection Well:
ft ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery EjSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test IStormwater Drainage ft' ft.
Experimental Technology DSubsidence Control ft. ft
Geothermal(Closed Loop) QTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) PROM TO DESCRIPTION(color,hardness,soil/rock type,grain sae,etc)
o ft. ao ft. Rem c/4..,
4.Date Well(s)Completed: y',2 3 2 VWell lD# sat‘ f. 9 0 ft. L1, d for el. C l 4 y
p
5a.Well Location: -/ 0 ft. /O to ft. 14'e.,4-t1 RPd rt.O(7 14.Chad Hargett 1 b 6 358ft- f�#42a_ st its*rv+e
Facility/Owner Name Facility IDB(if applicable) 35 p ft' 3 97 ft. 5o F' Rf}m1tL
230 Ingonish Dr., Gastonia, NC 28056 397 ft. L/02 HA-a.� 4 �- ' .,+/;
Physical Address,City,and Zip ft. ft.
Gaston 21.REMARKS JUL 2 )071
C Parcel Identification No.(PIN) m 1'
Y Ifd9::i,6rt:'C,i r-_ 3F^y^a",v JF.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: DWG.
(if well field,one lat/long is sufficient) 22.Cert' 'ni:
N W le iS4---at-d .23 a0zy
6.Is(are)the well(s)1% Permanent or []Temporary Signature of Certified Well C tractor 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: DYes or X}No with ISA NCAC 02C.0100 or ISA 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#2l 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 details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: i 0 2.. (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2@100') construction to the following:
10.Static water level below top of casing: -10 (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 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) --+ Method of test: blow 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 g O 7-' 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