GW1--06210_Well Construction - GW1_20230925

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: i;
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1.Well Contractor Information:
C.h a r//e- h/' -/'o/. 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
/ / �/,r)
ft. it ft. /4-
3 �f�llp ENO ft. P-8I 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
Company Name 0 ft. / )5 ft. 6*1 in- LJOA..‘A /�f/e__
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 14189 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. ft. 1' in.
3.Well Use(check well use): ft tt in.
17.Water Supply Well: - FROM SC��TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) 'Residential Water Supply(single) ft. ft. in.
Industrial/Commercial D Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL , EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: oft.
//ft.
I il;iLL C , 149raf ribt?k,
Monitoring (Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge 0 Groundwater Remediation
_ 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery DISalinity Barrier FROM -TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology D Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soiUrock type,grain size,etc.)
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Geothermal(Heating/Cooling Return) [Other(explain under#21 Remarks) . o ft, 1�/QU ft _L)C�
4.Date Well(s)Completed: 7-,2-/'aj Well ID# /'8 fft. I,�A ft. -IAA S
5a.Well Location: ye: ft. C"6 ft. gien1n 5RJ n
David Stone jig ft. 5-- ft. 66. A1 xo
Facility/Owner Name Facility ID#(if applicable) I!,'�ft. l(j ft ��` pdG�
300 Catawba Winds Dr. Belmont, NC 28012 ft. J ft.
j'
ft. ft. {^�;� ; / r 's
Physical Address,City,and Zip {`�k r f""i fuJ h 1. .1
Gaston 21.REMARKS
SEP 2 5 2023
. County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �,,.- ,�"1--;:a' ',Ur'
(if well field,one lat/long is sufficient) 22.Certificatio • I +GJ '
. N W 7- ii ..2-3
6.Is(are)the well(s) JC Permanent or ©ITemporary Signature of Certified Well Contractor' Date
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: I1Yes or D No 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
9.Total well depth below land surface: 3 60 (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: 9-3 (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) 3 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: /11)2.-- completion of well constructiontto the county health.department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016