GW1-2021-00369_Well Construction - GW1_20210315

WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only:
1.Well Contractor Information: V l/ /
I 7' 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
ft. t/v1
.� r_0 L 4 5 ft % ft. 19v�
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
James Darby Well Drilling, LLC FROM I TO DIAMETER T THICKNESS MATERIAL.
Company Name 0 ft ft. j \ d-
in. .5C �` nj.&(_
13355 16.INNER CASING OR TUBING(geothermal closed-loop) y
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) fL fL in.
3.Well Use(check well use): ft. fL in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLAT SIZE THICKNESS MATERIAL
i Agricultural []MunicipaL/Public tt ft. in.
J Geothermal(Heating/Cooling Supply) J Residential Water Supply(single) ft. ft. in,
_I Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
I Irrigation FROM TO MATERIAL EMPLACEMENAT-METHOD&AMOUNT
Non-Water Supply Well: Dft. ft r
:)Monitoring [Recovery & fa
Injection Well:
ft. ft.
-31 Aquifer Recharge E)Groundwater Remediation
19.SAND/GRAVEL PACK if a livable
Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL I EMPLACEMENT METHOD
]Aquifer Test []Stormwater Drainage ft. ft.
Experimental Technology 13Subsidence Control & ft.
I Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
ni Geothermal(Heating/Cooling Return) C Other(explain under#21 Remarks) I
FROM To DESCRIPTION color hardness,soil/rock rain size,etc
ft. \ ft. C
4.Date Well(s)Completed: ✓� Well ID# ft 16 ft
5a.Well Location: ft• `� ft' 6?)`N►' 43►i
Alan Eppley ft. -7o ft-
Facility/Owner Name Facility DW(if applicable) ft- 572 ,f� Lr7 C�
217 Riverloop Rd. Belmont, NC 28012 ft. ft.
Physical Address,City,and Zip V Ism
Gaston 21.REMARKS h ln
County Parcel Identification No.(PIN) NIAR 1 -5 2021
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certificati n: vE'="•Gi3
N W
6.Is(are)the well(s) X)Permanent or OTemporary Signature of Certified Well 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: DYes or Xi 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: 0 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (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 1@I00) construction to the following:
10.Static water level below top of casing: !y (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,rise^+^ 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) °'/ 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: lr'dZi completion of well construction to the county health dep ent of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016