GW1-2021-03628_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD (GW-1) ram► For Internal Use Only:
1.Well Contractor Information: kl3 Dhl
to j
1 �r, I'0t� � LV? 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
ft. f gq
ft ft
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LINR f alcable
FROM DTER TH MATE RIALJames Darby Well Drilling, LLC
Company Name in. ��Q '
166434 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) h• ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FF7ROMREE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ®Municipal/Public p ft. ft. in.
Geothermal(Heating/Cooling Supply) x Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) I&GROUT
I Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. Ii xn� U
Monitoring ID Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
I Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL, EMPLACEMENT METHOD
:)Aquifer Test OStormwater Drainage ft. ft.
1 Experimental Technology OSubsidence Control ft. ft.
1 Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
n Geothermal(Heating/Cooling Return) I Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,somrock type,grain sae,etc
® ft. 1,40 ft. /i
4.Date Well(s)Completed: ell ID# © ft. , 00 It C 'rk
ft. ft.
5a.Well Location:
Charles Beverly ft. ft. a -.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
517 Alex D Owens Kings Mountain, NC 28086 ft. ft.
Physical Address,City,and Zip ft. ft. A J
Cleveland 21.REMARKS r nrPrS1I1.
County Parcel Identification No.(PIN) 1^y S_c'.on
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.7on
N N /�
6.Is(are)the well(s) (KI Permanent or OTemporary Signature of Certified 1 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: nYes or )CI No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
1f 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-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: r 6 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dferent(example-3@200'and 2@10.0) construction to the following:
1
10.Static water level below top of casing: i 0 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service I
Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 1 A (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) Method of test:Blow 24c.For Water Supply&Iniection Wells: In addition to sending the form to
f the address(es) above, also submit one 'copy of this form within 30 days of
13b.Disinfection type: HTH Amount: —7 C! completion of well construction Ito the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016