GW1-2021-00366_Well Construction - GW1_20210315

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: /�'
;:VA" e4nn (1t/�(J�/j / 14.WATER ZONES
Well Contrac FROM TO DESCRIPTION
141D ft q2 ft � �n
4�o 2— 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 THICIdVESS MATERIAL
ft ft. 2S in. `�VC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
13281
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. fL in.
3.Well Use(check well use): fL ft. in.
17.
Water Supply Well: FROM SCREENTO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) xDResidential Water Supply(single) ft. ft, in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irri ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply WeII: D ft ft. _P
Monitoring DRecovery ft. ft
Injection Well:
ft. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK if a livable
Aquifer Storage and Recovery ❑ISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test []Stormwater Drainage ft. ft.
Experimental Technology DSubsidence Control ft. ft.
RGeothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) FROM TO DESCRIPTION(color,hardness,soittrock e, in sae,etc.)Other(explain under#21 Remarks) © fL 5 ft C►
a
4.Date Well(s)Completed: I A Well ID# 1?2.4 k !J' ft' 110 ft' C k�d
5a.Well Location: f" S f- o rD
James Dye ft %bo ft• l�A'p d ctxv
Facility/Owner Name Facility M#(if applicable) ft. ft.
1210 Wildflower Dr. Gastonia, NC 28056 fL ft.
Physical Address,City,and Zip ft. ft. • . I w
Gaston 21.REMARKS
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: „, 'ram. ��Sit^i. �IGiI
(ifwell field,one Iat/long is sufficient) 22.Certification: BLtI[ Sect"
N W -D. - C"
Mairl
6.Is(are)the well(s)[DPermanent or Temporary Si f fed Well 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: QYes or X)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 I 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: 200 (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: �X (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"i" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 1 A (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) 3o Method of test:Blow 24c.For Water SuoDly&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: 5 tk.• 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