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HomeMy WebLinkAboutGW1--05301_Well Construction - GW1_20230814 Print Form WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: 1.Well Contractor Information: 5-1-14 4 I el i`t Set Y? 14.WATER ZONES Well Contractor Name FROM TO DESCRIPTION 7-5' � 2,,O ft. a��s ft. wt,,• ear& gal is 5 F ri/13/23 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 ER THICKNESS MATERIAL Company Name ft `3 3 ft L I in. SP el/6 13994 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. 17.SCREEN Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL *Agricultural [Municipal/Public 0 ft. ft. in. "Geothermal(Heating/Cooling Supply) IX Residential Water Supply(single) ft. ft. in. *Industrial/Commercial DResidential Water Supply(shared) 18.GROUT I Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT Non-Water Supply Well: 6 ft. 2.+ ft. pole 00J' PO u tQ *Monitoring Recovery ft. ft. T'� Injection Well: ft. ft. *Aquifer Recharge D Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable) "'Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD ®I Aquifer Test DStormwater Drainage ft. ft. I*Experimental Technology D Subsidence Control ft. ft. ®I Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary) *Geothermal(Heating/Cooling Return) [j Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soil/rock type grain size eta) t, ft. 2-9 ft* Rdd ela ti 4.Date Well(s)Completed:6-'2-.4n7.3 Well ID# 211/ ft. 76 ft' ,gn,,..+y. 0../441 5a.Well Location: 7b ft- /17 f' 1-turGliui,ed. eo&V Cizact aa.K4-t, ) Rykar Homes 1a,7 ft. ,yq ft. 124W; ,, � , (0. b. *, r ^° ft. `f 7 ft. _'.n-. t Facility/Owner Name Facility ID#(if applicable) / ..i 5�..?-, 113 Lighthouse Church Ln, Gastonia, NC 28056 ft. ft. Al/G 1LI 2072 Physical Address,City,and Zip ft ft. Gaston 21.REMARKS -tl•E .+;n_.4:.7.i1 t r.."="o.V.,?,FJ Ut. County Parcel Identification No.(PIN) 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (if well field,one lat/long is sufficient) 22.Cer'`; on- N W it � - / 4.-4'-2b�3 6.Is(are)the well(s) Permanent or Temporary Signa of Certified We Contractor Date 0 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: DYes 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 L/l 9.Total well depth below land surface: a" / + (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: 14 3 (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) 15 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: 5 07- completion of well construction to the county health department of the county where constructed. Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources' Revised 2-22-2016