GW1--05301_Well Construction - GW1_20230814

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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