GW1--05297_Well Construction - GW1_20230814

IPrint Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
*-5--hlate.v k , S Orze2
14.WATER ZONES
Well Contractor Name i FROM TO DESCRIPTION
�� �. F°4 �J 61 ft. try ft. •�gefel Rea 14:5P n-L,
NC Well Contractor Certification Number ?/12rGQ ft. Aar/ ft Lt 41 / 5Q 0) 3�I Q sM/DO,p
15.OUTER CASING(for multi-cased wells)OR LINER(if a licabl Ot(J
James Darby Well Drilling, LLC FROM TO DIAMETER THICKNESS MATERIAL
Company Name ft. q) ft. 6 in. .)Q.' p V�
14020 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. ft. in.
17Water Supply Well: SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural jMunicipal/Public 0 ft ft. in.
Geothermal(Heating/Cooling Supply) DResidential 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: f) ft o��1 b ft �l f o�G pii 1Qo v Q
Monitoring Recovery ft ft. r
Injection Well:
ft. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test UStormwater Drainage
ft. ft.
Experimental Technology OSubsidence Control ft rt.
Geothermal(Closed Loop) ❑ITracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
soil/rock type grain size etc.)
/ o ft ►g ft. Reg Cl*•y
4.Date Well(s)Completed: -3O 23 Well ID# i 8 ft 7 D it i3Rl adn 1 C 1Iq,y
5a.Well Location: 40 ft. 53 ft. I l_+ _Rc I j3go w rI e...1.41
J
Peter Lasne s!3 ft. ft. �QAn;
Facility/Owner Name Facility ID#(if applicable)
ft ft.
4529 Bud Wilson Rd. Gastonia, NC 28056 ft. ft. j. ,k 5 1t sP r%
Physical Address,City,and Zip ft. ft , 1
Gaston 21.REMARKS AUG /073
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: f3V5t0r7intr-1
(if well field,one lat/long is sufficient) 22.Cer; ��,n Ark.
N W / ® k We l�^3or1OZ3
X Signat - .•Certified We 1 ontractor Date
6.Is(are)the well(s)1. Permanent or ❑ITemporary
By signing this form,I hereby certifi,that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or lNo 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 I 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:3l (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 00'and//2��@100') construction to the following:
10.Static water level below top of casing: 5' (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
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) 10 0 Method of test: Blow 24c.For Water Supply&Injection 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 A 2, 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