GW1--05296_Well Construction - GW1_20230814

WELL CONSTRUCTION RECORD (GW-1) ,, For Internal Use Only:
1.Well Contractor Information:`_ ,��--F t i
CAA Yid 1 iCAA°b 3l/2-.3 14.WATER ZONES
���/// FROM TO DESCRIPTION
Well Contractor Name
3155 '110 ft. 11 -)._ft. �0 h f+�
NC Well Contractor Certification Number ` t , I�J,j \ �r ��r�
15.OUTER CAS G(for multi-cased wells)OR LINER(if ap licable)
James Darby Well Drilling, LLC FROM TO DIAMETER THICKNESS MATERIIAL
t10 ft. ( 0 ft. 6 114 in. 5 Q2�� FA,
Company Name (�
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit# 14196 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.
Water Supply Well: 17.SCREEN
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 0Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OlResidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q it. rho fL 132in\n,ti.tte Lyfiee,it, ea ire
Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge 0Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DIStormwater Drainage ft. it.
Experimental Technology 0 Subsidence Control ft. ft.
Geothermal(Closed Loop) jTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,
Geothermal(Heating/Cooling Return) 0Other(explain under#21 Remarks) grain size,etc.)
C ft. l to f`. CtL
4.Date Well(s)Completed: �- 2 2-3-2✓ Well ID# ti Q ft. 3uz. ft. �- -5 o�
5a.Well Location: �I_ ft. I_f„ ft. 171 '5()t
Stephen Ferguson (JA,t ft. -7D ft. 15 ATV W --kt,• fee- P---
Facility/Owner Name Facility ID#(if applicable) 76 ft. V
Q!` ,s-
ft. fry 13 C 1yi(i�
162 Wilson Farm Rd. Gastonia, NC 28056 eO ft. I13��ft. �l.vr`"�. VoG =
Physical Address,City,and Zip ft. ft. - I..,L.i tVV.4;„:r
Gaston 21.REMARKS
AUU I �. 2023
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Ir-`ri,' 'ri err.^`..,-.'r ry r'^:i
(if well field,one lot/long is sufficient) 22.Certifrcati n: DWO/30.
N W 7 %- 2-3.23
6.Is(are)the well(s) X Permanent or Temporary Signa re of Certified Well Contractor Date
By signing this form,1 hereby certifir that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: JYes or 'XONo 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: 1 ,J (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 2 ( (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 Injection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 4\ `t 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) �0 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: Po(12, completion of well construction,to the county health department of the county
where constructed. ,
1
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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