GW1-2021-07824_Well Construction - GW1_20211102

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
A} q l
� � •e• 1 V 1�i�/l(� 15 �6�f!g !/ 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
' & ft. 1y7 ft.
315'S g ft. 1% 5' OL,
NC Well Contractor Certification Number 15.IO1UTER CASING for multi-cased wells)OR LINER if a licable
James Darby Well Drilling, LLC FROM TO DIAMETER THICKNESS MATERIAL
ft. 1 fL &' in. o//f Q2�
Company Name 13509 \ f/ r
16.INNER CASING OR TUBING eofhermal closed-too
2.Well CDnS[rUCtlOn Permit#: FROM TO DIAMETER THICKNESS MATERIAL
l,i.st all applicable+cell con.sinution permits(i.e. Ill('.County.Stale, I arlance.etc.) ft. ft. in.
3.Well Use(check well use): rt. R. in.
Water Supply Well: 17.SCREEN
pp) FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public 0 ft. ft. in,
Geothermal(Heating/Cooling Supply) 'Residential Water Supply(single) ft. R. in,
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrl aUOn FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. &Ay,_iy tQ -
Monitoring DRecovery ft. ft. l
Injection Well:
rt. rt.
Aquifer Recharge DGrOLindwater Remediation
19.SAND/GRAVEL PACK ifa licable
' Aquifer Storage and Recovery Dsalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ElStormwater Drainage ft. ft.
__ Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type. rain size,etc.)
ft. ft. I "
4.Date Well(s)Completed: /Q Well ID# ft. ft.
5a.Well Location:
Lisa Nolen 11v ft. I IT- ft. w�•-� �-�
Facility/Owner Name Facility IDIt(if applicable) 0
2825 Crowders Creek Rd., Gastonia, NC 28052 V
Physical Address,City.and Zip ft. ft.
Qc 1 —\ 21.REMARKS •:
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one tat/long is sufficient) 22.Cer' Ication:
N W v 2A
6.Is(are)the well(s) Permanent or OTemporary Signature of Certified Well Contractor Date
4v.si,KmnK this Jbrm, I hereby cerly.v that the well(s) was(were)constructed in accordance
7.Is this a repair to an existing well: QIYes or H)No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well('orr.sn•ticlion,'YOrrdardc and that a
/(this is a repair fill out knarra well construction inlbrnrraion and explain the nature of the ropy ol'Ihi.s record has been provided to the well owner.
repair under 21 remarks section or on the hack of ihis fimn.
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: /Q`[/ ✓ (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
l'or mtaliple wells list all depths il'thIlerew(example-3@200'mrd 2 a l00') construction to the following:
10.Static water level below top of casing: 23 (ft.) Division of Water Resources,Information Processing Unit,
/l water Ierel is ahme crrcin/,rr.ce" 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,i Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.field(gpm) P J Method of test: Blow 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: HTH Amount: �6 completion of well construction to the county health department of the county
where constructed.
Fonn GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016