GW1--05298_Well Construction - GW1_20230814

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
5--h4,4/'e S el-2ett 14.WATER ZONES
or Name FROM TO DESCRIPTION
Well Contractor$� P-at/Veld
7/g/�3 j j8 ft. ft. n*e..d-t..c....41 Roe.,k
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
James Darby Well Drilling, LLC FROM TO DIAMETER THICKNESS MATERIAL
D ft. is/ ft. G in. SDR 1( p ve
Company Name +ems f�
14167 16.INNER CASING OR TURING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIG County,State,Variance,etc.) 4 ft. 137 ft. .4 in. s'�t--,iO P11(Ii
3.Well Use(check well use): it.17. ft' in.
Water Supply Well: FROM SCREENTO DIAMETER T SIZE THICKNESS MATERIAL
Agricultural DMunicipalPublic in.
137 ft. 1$
7ft. `�0 Se 11--t(o pee,
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: b ft, 6 ft• Hoe Mu, p B u a
Monitoring DRecovcry ft. ft.
Injection Well: ft. ft.
Aquifer Recharge 0Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery D Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test EStormwater Drainage ft. ft.
Experimental Technology D Subsidence Control ft. ft.
Geothermal(Closed Loop) FJTracer 20.DRILLING LOG(attach additional sheets if necessary)
_ FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) 0Other(explain under#2I Remarks) I
p ft. ;0 ft. Rex! a./ii-i
4.Date Well(s)Completed: 7-/a--a073 Well ID# ..0 ft. 76 ft. &won C` I4 y
5a.Well Location: 70 ft. BD ft. clay 4 Roe,k Ire:"
Dawn Timson tip ft. 1,5'8 ft. g>zPrue,I
Facility/Owner Name Facility ID#(if applicable) ft. ft. r7 .,-. fr.:•:', ±A .
',
6466 Lewis Rd. Kings Mountain, NC 28086 ft. ft. a '•+-..t✓L.b y 1--1--
Physical Address,City,and Zip ft. ft. AU G 1 z.: 2023
Gaston 21.REMARKS
,<., . : n 7,rcc.:y vr..
County Parcel Identification No.(PIN) Ir"�'.:•. V
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Cert • o h: 410
N W 'OW, ,, /_ r�./. /-/a- D23
6.Is(are)the well(s) Permanent or Temporary Signature of Certified ell Contract Date
�X)
By signing this form,I hereby certiO that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: EjYes or jNo with 1SA NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,full 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: 15, (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths(f different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: S Z (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 Tniection 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) AD 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: 6 Oz completion of well construction 4o 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