GW1-2021-03653_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: TRx !
14.RATER ZONES
Well Contractor Name FROM TO DESCRIPTION
rt. M
452)2—A rr. ft. 10
NC Well Contractor Certification Number 15.OUTER CASING for multi=cased wells OR LINER ifa licable
James Darby Well Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
" r
Company Name ft. ((o ft. � in. QK21 PVC
-16.INNER CASING OR TUBING 'eothermal closed-loop)
'
2.WCII CODStrUC[IDn Permit#: J J FROM TO DIAMETER THICKNESS MATERIAL
l.i.sl all applicable well construction permits(i.e. (11C,Corm[`, ,;Tale, lariance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
PPY FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
Agricultural Municipal/Public 0 ft. ft. in:
Geothermal(Heating/Cooling Supply) ]Residential Water Supply(single) ft. ft. in.
Industrial/Commercial []Residential Water Supply(shared) 18.GROUT
Irri anon
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. t2z ft. 2q 6 �1Air
Monitoring ORecovery
Injection Well:
Aquifer Recharge oGrOUndwater Remediation
19.SAND/GRAVEL PACK if a licable
Aquifer Storage and Recovery [3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test JDStormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.'DRILLING LOG'attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type, rain size,etc.)
Geothermal(Heating/Cooling Return) I O[her(explain under#21 Remarks) 0 rt. it. C��
4.Date Well(s)Completed: Well ID# 'f2S ft. rj ft. c. /
,Sft. `C( ft. i�Gl
Sa.Well Location: `�'
Joel Self I "CV, ,I,,.\
Facility/Owner Name Facility ID4(if applicable) ft. ft. �°i e�7
9 Bell St. Belmont, NC 28012
Physical Address,City,and Zip ft. ft. (\ V\
Gaston 21.REMARKS
J�J
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
6.Is(are)the well(s)ID or E3Temporary Signature of-Certified well Contractor Date
81 signing 1hi.s Junin. 1 hereby cetob;that the ivell(s)was(were)con.sirucled in accordance
7.Is this a repair to an existing well: DIYes or X INo wilt I5A NCAC o2C.o1no or I5A NCAC 02C.02nn Well Construction Standar(A and chat a
/f this is a repair,/ill nut known well construction in(nrination and explain the nalure oflhe copy oflhic record has been provided to the well owner.
repair under 21 remarks.section or on the hack o/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 ofwells construction details. You may also attach additional pages ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: S2® (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
bor inulliple wells list all depths it'eh ferenl(example-3@ 200'and 2 a 100') construction to the following:
10.Static water level below top of casing: (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
( 1
13a.Yield(gpm) � ( /Method of test: BIOW 24c. For Water Supply& Infection 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: I IThI Amount: Z�i� completion of well construction to 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