GW1-2021-07837_Well Construction - GW1_20211102

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
L y a IS 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
1b)-fir. M
J3 3�aft. �ft. Pw`
NC Well Contractor Certification Number 15.OUTER CASING
James Darby Well Drilling LLC ells ORLINER ifa-lieable or mu tt case w
FROM TO DIAMETER' THICKNESS MATERIAL
to ft. ft. in.
Company Name I /I/] �(J(/y�
,,//�`/JS 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
Lisi all applicahlc ire//construction pernrils(i.e. 1/1C,County,S•lale,Variance.etc-.) ft. ft.
3.Well Use(check well use): ft. 1t. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) xResidential Water Supply(single) ft ft. in.
Industrial/Commercial Residential Water Supply(shared) IS.GROUT
irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. 1t. `
Monitoring Recovery
Injection Well:
ft. fr.
Aquifer Recharge DGroundwater Remediation 19.'SAND/GRAVELPACK(if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology [3Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheers if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) YFROM
ft. ON(colog hardness,soilhock e, �in sip,eu.)
11TO DESCRIPTI4.Date Wells)Completed /0�'�'� Well ID# fLwe ,C•_.1„5a.Well Location: `� �_-t_? `I 'y
James Richardson ft. ft.
Facility/Owner Name Facility ID9(ifapplicable)
5028 Lewis Rd., Gastonia NC 28052 ft. ft.
Physical Address.City,and Zip ft. ft.
( •.:,,s'. � ;;`,n,,,,,
Gaston 21.REMARKS
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.Certifie. ion
N W. '
6.Is(are)the well(s) Permanent or OTemporary Signature ofCertified Well Contractor Date
13y signing This.1brin, 1 hereby c•erli&that lire well(s)it-as(were)constructed in accordance
7.Is this a repair to an existing well: DYes or X No with 15A NCAC 02C.0100 or 15A NCAC b2C.0200 Well Construction Standards and that a
if this is a repair,fi//out known well construction information and explain the nature of the copy of lhis record has been provided to the well owner.
repair under'21 rernarks section or on the back(?/ihi.s jbrm.
23.Site diagram or additional well details:
S.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: (�f� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1 J t (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Pbr multiple wells list al/depdrs ijdi/ferent(example-3 a 200'and 2@/00') Q construction to the following:
10.Static water level below top of casing: 3 1/ (ft.) Division of Water Resources,Information Processing Unit,
l/lrater level is ahove casing,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 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& Infection Wells: In addition to sending the form to
the address(es) above, also submits one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: �Vrr' completion of well construction to the county health department of the county
where constructed.
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Font GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016