GW1-2021-02320_Well Construction - GW1_20210527

WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only:
1.Well Contractor Information:
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14.WATER ZONES
FROM TO I DESCRIPTION
Well Contractor Name
3 I� �5•�ft. 15-7 fr. I S•Wh�
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
O ft. I ag ft. /n ,Iq in. l/_
Company Name 13339 v�
16.INNER CASING OR TUBING eothermal 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. % in.
17.
Water Supply Well: FROSMREE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public 0 ft. ft. in.
i Geothermal(Heating/Cooling Supply) X,Residential Water Supply(single) fL ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
1 Irrigation FROM I TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft 90 ft. &yrJ5Wt6Uw1° , 111_
Monitoring Recovery ft. ft.
Injection Well:
ft ft.
1 Aquifer Recharge [)Groundwater Remediation
19.SAND/GRAVEL PACK if a licnble
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage tt. ft
:)Experimental Technology Subsidence Control ft. fL
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
i Geothermal(Heating/Cooling Return) nOthCT(explain under#21 Remarks) FROMI TO DESCRIPTION color,hardness,soil/mck tyM grain size,etc
` 't It.
4.Date Well(s)Completed: 1 AA Well ID# a92
5a.Well Location: (T2ft. fr.
Buller River Development °
Facility/Owner Name Facility ID#(if applicable) ft.
212 Crawford Road, Gastonia, NC 28056 ft. Cq>.
Physical Address,City,and Zip ft.
Gaston 21.REMARKS IVI,At
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwe0 field,one lat/long is sufficient) 22.Certification:
N W c
6.Is(are)the well(s) xl Permanent or OTemporary gnature of Certified 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 Yes or 19No 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 alsolattach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: C/y (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: 3 (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+" 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
(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 SuuDly&Iniect ion 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: r1tr1 Amount: Alk- completion of well construction to the county health department of the county
WI1P.rP.C.(1nCtT11('.ft;;�„•,
- Revised 2-22-2016
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources
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