GW1-2023-02185_Well Construction - GW1_20230306

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
IQ yj e s�J? 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
�� 19 {—Gj 1 ft. ? fr. x,,t rt e f-�a 2e elL
1/�y A)j ft ft.
NC Well Contractor Certification Number 15.OUTER CASING1�9 for multi-cased wells OR LINER if a licable
James Darby Well Drilling, LLC FROM TO DIAMETER THICKNESS MATERIAL
Company Name (j fL ft. 41� in. 5DE'2.1
14034 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.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): & ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
HAgricultural E3Municipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) EiResidential Water Supply(single) ft. ft. in,
Industrial/Commercial [3Residential Water Supply(shared) 18.GROUT
—Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: `2
ft. . ft. Na(e- ( P
_Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
_ 19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery [DSalinity Barrier FROM TO MATERIAL EDiPLACEMENT METHOD
Aquifer Test []Stormwater Drainage ft. ft.
Experimental Technology E3Subsidence Control ft. ft.
Geothermal(Closed Loop) [ITracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) M Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soilhr ck type,grain size,etc
?? v EL tS �L ft. _ tZL R jam-e C
4.Date Well(s)Completed: /' g— oI�Well ID# � & e ft. / 1"
Sa.Well Location: yo I-
V ft kis
Andino Edil 71ft 8'o ft G
Facility/Owner Name Facility ID#(if applicable) VC It. O ft. G Er
+ µ J : yL
2212 Hephzibah Church Rd. Bessemer City, NC 28016 ft
Physical Address,City,and Zip ft. ft.
Gaston
21.REMARKS hn Q
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certifi n• ��77 N W - 9 & t�A! /,?`i�►t�Z-3
6.Is(are)the well(s) IX Permanent or OTemporary Sign Ceffiffied Well ontractor 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: OYes or INo 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 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: y d a (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
Por multiple wells list all depths if different(example-3@200'and 2Q100') construction to the following:
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 1/4" (�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) 1 Method of test- Blow 24c.For Water Supply&Infection 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: e Z completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016