GW1-2021-07829_Well Construction - GW1_20211102

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
,S 14 la,I 14J,WATER ZONES
Well Contractor Name Q FROM TO DESCRIPTION
ft.
fl' ('71, f"
NC Well Contractor CertificationNumber 15.OUTER CASING formulfr-cased wells'OR LINE ifa'lic Ie
James Darby Well Drilling LLC FROM TO DIAMETER THICKNESS MAY RIAL
ft. D ft. in. SD Q—O9 I v
Company Name a� �
INNER CASING OR TUBING leenthermal closed-l000ll
2.Well Construction Permit#: 1/( FROM TO DIAMETER THICKNESS MATERIAL
l.i.cr all applicable well e•anvrretclion perrrriiv(i.e. UlC,CounlY,Sane,Variance,ere•.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.tSCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) EfResidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
-1irrilzation
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 6 fr. �2_'7 1 ; 1V POt1 �7 hpm
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
Aquifer Storage and Recovery Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
Aquiter Test E)Stormwater Drainage ft. ft-
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) DTracer 20 DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/CoolingReturn) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
© ft. 15 ft. Re�_" C 1
4.Date Well(s)Completed: t Well ID# s fr. tr. W ft 2 e'l el I
5a.Well Location: ft. ft. h C I4-
Stover Construction L4 v ft. ft. ,KeA k;e,k "
Facility/Owner Name Facility ID#(if applicable) ft. ,2fr•
1213 Steepleview Ct., Stanley NC 28164 ft. ft.
Physical Address,City,and Zip ft. ft. ` •1
Gaston 21.REMARKs
n'l
County Parcel Identification No.(PIN) t
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ' Q ~
(if well field,one lat/long is sufficient) 22JCert'/'
tiow
N W
6.Islam)the well(s)o Permanent or Temporary SiiiiatureofCertifiedWel7on actor Date
Hy signing dr/s.fornr,1 hereby ceritfy dial the u•ell(v)u•as(here)c•onsiruc•red in accordance
7.Is this a repair to an existing well: Oyes or XBNo a ith 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Conrrruction Standards and that a
if this is a repair,fil/our known use//tints/ruction iglbrtnarion and explain the nature of'rhe copy oj'this record has been provided In fire u•e//oivner.
repair under t:21 remarks section or on the hack of this/nrin.
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 also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: / O (ft-) 24a. For All Wells: Submit this fonn within 30 days of completion of well
/ar ntu/lip/e ur//s/ir/all dcprhv/di/Jere»t(example-3(n 2nn•and 2@1 nn') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
ff uarer level is above casing,use-- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 /4 (in.) 24b. For Injection 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) 3 5 Method of test: blow 24c. For Water Supply& Injectiond 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: D L 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