GW1--06477_Well Construction - GW1_20231002

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: I
1.Well Contractor Information: 1
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14.WATER ZONES $
Well Contractor Name FROM TO DESCRIPTION
3/ � Ke-o 84, ft. ft. -7 1,,.
NC Well Contractor Certification Number 01/02 7 41.3 13c ft. /3's rt. tse
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15.OUTER CASING(for multi-casedti ( wells)OR LINER(if ap licable)
James Darby Well Drilling, LLC FROM TO DIAMETER THICKNESS MATERIAL
Company Name O ft. ` 7 ft. GIN' in. Six .\ O L
14103 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
i Agricultural [)Municipal/Public ft. ft. in.
•,Geothermal(Heating/Cooling Supply) MI Residential Water Supply(single) ft. ft. i I
*!Industrial/Commercial DResidential Water Supply(shared) 18.GROUT -
I Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: D tt. 3-0 ft. snA ( I,�/ e jsn.IIt
miIMonitoring DRecovery ft. ft.
Injection Well:
ft. fL
NI Aquifer Recharge [)Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
*Aquifer Storage and Recovery [)Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ill Aquifer Test QJStormwater Drainage ft. ft.
a Experimental Technology ![)' Subsidence Control ft. ft.
i!Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
s Geothermal(Heating/Cooling Return) [)Other(explain under#21 Remarks)
/1' ft. ft. • K217eJ /
4.Date Well(s)Completed: -°2Y'02-3 Well ID# /22. x ft. "TM Se. \
t.
5a.Well Location: f L 3 2J 13 ilw.- St,;I
Jeff Stover .3 ft. 5'7 ft. .'iris tote, W e... .sncit Igoe _
Facility/Owner Name Facility ID#(if applicable) V\� ft. pbo ft. �N /�nQ�I
377 Meek Rd., Gastonia, NC 28056 ft. ft. /
Physical Address,City,and Zip ft. ft. r..y r ';',, `iv �2 a
Gaston 21.REMARKS a t. '--I
County Parcel Identification No.(PIN) 0 n Q
2 2023
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: - '.2 lUnib:
(if well field,one lat/long is sufficient) 22.Certification: ln`f"i 'DV;i%1:.
N W 6' 2A- 23
6.Is(are)the well(s)IX Permanent or lDTemporary 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: [)Yes or ONo 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
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9.Total well depth below land surface: t 00 (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: 0 (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 Infection 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) /a Method of test: Blow 24c.For Water Supply&Iniection Wells: In addition to sending the form to
p� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: Bolt completion of well construction to'the county health department of the county
where constructed.
I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources ' Revised 2-22-2016