GW1-2022-03085_Well Construction - GW1_20220307

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WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor In rmation:
Jay I
14.WATER ZONES
Well Contact r Name FROM TO q DESCRIPTION
fL
SJON—4 fk ft.
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 MATERIAL
O fk ��t]I ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC,County,State,Variance,etc.) fk ft. in.
3.Well Use(check well use): & fk in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER. SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipat/Public U fk ft. in.
Geothermal(Heating/Cooling Supply) xi Residential Water Supply(single) fL ft in,
Industrial/Commercial Dj Residential Water Supply(shared)
18.GROUT
111rrigation FROM TO MATERIAL LACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft-
ft-
I Monitoring J Recovery ft. %
Injection Well:
ft. ft.
I 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 attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) I
FROM TO DES ox color,hardness,soiVrock type,grain sire,etc
O fk fk ReS
4.Date Well(s)Completed: Well ID# ft f �/j„//,_JjQ/r
59.Well Location: fk ft- 149 4/& /FAO -e"
Jorge Lopez fk fk r W t
Facility/Owner Name Facility ID#(if applicable) fk fk
2705 Birchfield Lane, Gastonia NC 28056 fk ft.
Physical Address,City,and Zip ft. ft. P P
Gaston 21.REMARKS
County Parcel Identification No.(PIN)
MAR 0 7 7027
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat(long is sufficient) 22.Certification:
N W
6.Is(are)the well(s)ox Permanent or 13Temporary Si of rtified Contract Da
y signing this form,1 hereby c t fy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or x]No with 15A NCAC 02C.0100 or A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to;the well owner.
repair under#21 remarks section or on the back of 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 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
1
9.Total well depth below land surface: fJ (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example- 00'and 2@1001) construction to the following:
10.Static water level below top of casing: 3 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 /4 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
rota 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&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: 0-3-1 completion of well construction to the county health department of the county
where constructed. I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources: Revised 2-22-2016