GW1-2021-07826_Well Construction - GW1_20211102

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
.5+P,4t?(./ J P�1Z�12 14.'WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
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NC Well Contractor Certification Number 15.OUTER CASING:for multi-cased w ells'OR LINER if op'livable
James Darby Well Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
Company Name d ft. j D��i 1. r L in.
1 �]326 16.INNER CASING OR TUBIN (geothermal closed-loop)
2.Well Construction Permit#' J FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well c•nnstnucuon permits(i.e.I/W.Cotn 4,,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural Municipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) x Residential Water Supply(single) s leeW go ft. in. w
Industrial/Commercial Residential Water Supply(shared) 18.GROUT f,
f Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: D ft. in ft. I O G 1,E � P
1 Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attachadditional heels if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION ft. ft. (color,hardness,sontnck type,gimin sin,etc.)
4.Date Well(s)Completed: S, —,2a2/Well ID# ft. fr.
5a.Well Location: ft. ft. �Tt
Richard Reeger ft. ft. ._
Facility/Owner Name Facility ID#(ifapplicable)
ft. fr.
112 Braswell Dr. Gastonia, NC 28056 ft. ft. ,
Physical Address,City,and Zip ft. ft. r %1Su
Gaston 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latilong is sufficient) 22.Certifl tion:
N W
6.Is(are)the well(s)Jq Permanent or OTemporary Sig f ertified Wellkofitractoi Date
Hy.signing tu.s Joan, I herehy verb that the well(v)was(were)constructed in accordance
7.Is this a repair to an existing well: [jYes or H)No with 15A NC'AC 02C.0100 or 15A NCA('02C.0200 Well('onvinee•tion Standardv and that a
tf this is a repair..fill not known well construction tnlnrmation and explain the nature of the copy olihiv record has been provided to the n•ell owner.
repair under.r21 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 of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 7 00 24a. For All Wells: Submit this form within 30 days of completion of well
Vor multiple wells lint all depths q diftrent(example-33@00200'and 2@0100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
I(water level is above caving,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 fonn 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,
L13a.Vield(gpm)
ER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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
fection type: HTH Amount: �Z completion of well construction to!the county health department of the county
where constructed. i
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Font GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-2,