GW1--06209_Well Construction - GW1_20230925

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
�� I i
S 11I S el-z erL 14.WATER ZONES
Well Contractor Name / FROM TO DESCRIPTION
�� //e ft. /12. ft. 3 itt
I �.� VIg'f,13 -230 ft. Z,yo it z�K e .� ., 4.-1..4./ el 30 pani
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
Company Name d ft. 9 , ft. & ! in. .cD It2/ IQV`1
13823 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
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
N'Agricultural DMunicipal/Public ft. ft. in.
N Geothermal(Heeting/Cooling Supply) IX Residential Water Supply(single) ft. ft. in.
1Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
!Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: b ft. .2 ( ft. be_ p1 try p0 Utt
II Monitoring ORecovery ft. ft.
Injection Well: -
ft. ft.
III Aquifer Recharge EiGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
NI Aquifer Storage and Recovery 0ISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
IiIAquifer Test [3Stormwater Drainage ft. ft.
N Experimental Technology • QSubsidence Control ft. ft.
III Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return)rn �1QlOther(explain under#21 Remarks) ft. 1f ft. gQ"1 j�
41
4.Date Well(s)Completed: 7 17 d0!t3Nlraim 1 t! ft. La 0 ft. S 71 �tr a LaC,I y
5a.WellLocation: t`ob ft. 37 ft' Roe K,t- ItC�Irty YKIxf
Giraldo Ricardo ?,7 ft. /ao ft. c fuatlt-).e it)/5..FT _spiffy
Facility/Owner Name Facility ID#(if applicable) lolb ft. 277 ft /�ae ,/ LJ p/ue a Gi AA-n:-Fe
3035 Fallswood Dr., Gastonia, NC 28052 ft. ft.
Physical Address,City,and Zip ft. ft. P., $�F'!s Y r r")
Gaston 21.REMARKS [i^��� '� /
• County Parcel Identification No.(PIN) - S E P 2 5 2023
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 'igr {V o> �„:,
(if well field,one let/long is sufficient) 22.Ce ' c lion:
N W
X 4 .4._ 7�/g oz3
6.Is(are)the well(s)0Permanent or OTemporary Signature of Certified W Contracto, Date
By signing this form,I hereby cerhfy'that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: fI Yes or X No with 15A NCAC 02C.0100 or ISA 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 page4o 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 INSTRUCTION S
9.Total well depth below land surface: 2. 5 (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 a�2U0'and 2Q100') construction to the following: 1,
10.Static water level below top of casing: S. (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail ServiceCenter,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/4 (in.) 24b.ForIniection 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: f '
(i.e.auger,rotary,cable,direct push,etc.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
•13a.Yield(gpm) 3 0 Method of test: Blow 24c.For Water Supply&Injection n 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 O 2, completion of well construction'tol 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