GW1-2023-02176_Well Construction - GW1_20230306

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
1 �� /—���� d ft. 4 it. tJdF.
�� ft. I "'
NC Well Contractor Certification Number �l /Z3 15.OUTER CASING for multi-cased wells OR LINER if a licable
James Darby Well Drilling, LLC FROM TO DIAMETER TIME& MATERIAL
d ft. 12 ft G $ ; in. GD(t--Xl PA
Company Name J
16.INNER CASING OR TUBING eothermal closed-loop)
13736
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(I.e.UIC,County•State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.
Water Supply Well: FROM SCREENTO DIAMETER SLOT SIZE THICKNESS MATERIAL
I Agricultural [DMunicipal/Public ft. fL in.
I Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in•
31,Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
—1 Irrigation FROM TO MATERIAL EMPLACEMENT METHOD AMOUNT
Non-Water Supply Well: 0 ft. 0 ft Me P1 u .5-7
I Monitoring OI Recovery ft. ft.
Injection Well:
ft. ft.
I Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)_
I Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
I Aquifer Test DStormwater Drainage ft. ft.
I Experimental Technology DSubsidence Control ft. ft.
I Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soiltrock e, rain size,etc.
I Geothermal(Hearing/Cooling Return) Other(explain under#21 Remarks) p ft. 5 ft. L7'
4.Date Well(s)Completed: 12,l8 XLWell um ft. ft.
5a.Well Location: 60 ft. S ao-w✓t C
Phillip Jervey Roper
Facility/Owner Name Facility ID#(if applicable) ft. ft.
5603 Arrowood Dr. Gastonia, NC 28056 ft. ft. MAR 0 i 2023
Physical Address,City,and Zip ft. ft.
Gaston 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iatflong is sufficient) 22•Cer' ca'on:
N W /�ag ap 3z
6.Is(are)the well(s)OPermanent or DTemporary Si re of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 0Yes or QNo with 15A NCAC 02C.0100 or 15A 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 OW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: a SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 / (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijjerent(example-3@200'and 2@100� construction to the following:
10.Static water level below top of casing: (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 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) L 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: 7 i9.y completion of well construction to the county health department of the county
where constructed. i
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016