GW1-2021-00519_Well Construction - GW1_20211222

WELL CONSTRUCTION RECORD (GW-1) y For Internal Use Only:
1.Well Contractor Information: ~
14.WATER ZONES
u
Well Contractor Name FROM TO DESCRIPTION
arr. rr.
NC Well Contractor Certification Number 15.OUTER CASING`for multi-cased wells OR'LINER if a livable
James Darby Well Drilling LLC FROM TO DIAMETER THICKNESS MA�TpERIAL
ft. 52.0. G� in. S�-9.I 1 v a/
Company Name �/�
13
S'rl � 16.INNER CASING OR TUBING(geothermal closed-too
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
l,i.sl all applicable well con.cbvction permits(i.e.I//(:,County,Slate, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. IS ft• le l i QoL'?,
Monitoring ORecovery ft. 11 ft'
Injection Well:
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)6le
Aquifer Storage and Recovery Osalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test []Stormwater Drainage
Experimental Technology OSubsidence Control
Geothermal(Closed Loop) OTracer 20.DRILLING LUG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soit/rock type,grain size,etc.
7 b ft. nJ /�
4.Date Well(s)Completed: _ 7- :Zt Well ID# ft. 37 ft. wit-0r 1x- +54-t
5a.Well Location: Z7 R. 8 ft. y-2A-1-4-0 d Ab C 1Z
Aaron Hines ft. ft. Al•, 24 4�r_-
Facility/Owner Name Facility ID#(if applicable) ft. ft.
906 Dallas Stanley Hwy, Dallas, NC 28034 90 rr. ;L3
Physical Address,City,and Zip
Gaston ,21.-REMARKS
2
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iattlong is sufficient) 22.Cer ation
N W 42" -..262-1
6.Is(are)the well(s)o Permanent or E3Temporary S" natu a of Certified w Contracto Date
Hy.signing this farm, l hereby sera/j,that the well(s) was(were)constructed in accordance
7.Is this a repair to an existing well: EJYes or allo with 15A NCAC 02C.0100 or 15A MAC 02C.0200 Well Constntction Standards and that a
If this is a repair,ill out known well construction information and urplain the nature n(the copy gl"this record has been provided to the well owner.
repair under..21 rentarks section or on the hack n/Yhis farm.
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 4o 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: SUBMITTAL INSTRUCTIONS
f�
9.Total well depth below land surface: bA (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
Vor multiple wells list all depths#di%%rent(example-3 c)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,
//water level is above casing,use" ' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 1/4 (in.) 24b. For Iniection 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) / �Jf Method of test: blow 24c. For Water SunDly& Iniection 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: O'y 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