GW1--07357_Well Construction - GW1_20231113

, I Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: j
Ckwr\,t 40 T C kikoCe. 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
.vi5 -. edi1010/L3 i js ft. /4 ft. /
NC Well Contractor Certification Number
�� ft. i//_l ft. /` r�
15.OUTER CASING(for multi-caseda wells)OR LINER(if ap licable)
James Darby Well Drilling, LLC FROM TO DIAMETER THICKNESS MATERIAL
1
Company Name .1N
n ft. eh
l ft. /_yq . in. 5 me i Z ff_`
14016 16NER CASING OR TUBING(geothermal closed-loop) P
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. en-
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 0Municipal/Public 0 ft- ft. in.
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in:
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: yr ft. ft. yz•4nA � ,l (3`0t 7
Monitoring Recovery ft. ft. tJi� 1�'�
- - Injection-Well: - - - - - -
ft. ft.
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery D Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology D Subsidence Control H. ft.
Geothermal(Closed Loop) OITracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) riOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soil/rock type grain size,etc.)
0 ft. tit ft. /�r[v_7
4.Date Well(s)Completed: 9' /2 s3 Well ID# [9 ft. 3t ft• "�ZK & 1�b`•l\r
5a.Well Location: 3C ft 6 i ft. Vyr.)24-__ ii,
Dustin Millwood col ft. $,7 ft. 7(r1M.e Uhea.Lg._ OC1t---
Facility/Owner Name Facility ID#(if applicable) ((JJ Qet ft. 6100 ft. C r ecY j�
400 Doc Wehunt Rd. Cherryville, NC 28021 ft. ft. W`�
Physical Address,City,and Zip ft. ft.
Gaston 21.REMARKS t. • . . ,
County Parcel Identification No.(PIN)
NUV 1 2023
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: '
(if well field,one lat/long is sufficient) 22.Certification: _ ,,,,1,
N W (jaz,„:„.. �.) [�': � C`
6.Is(are)the well(s)JPermanent or DTemporary Signature of Certified Well Cractor Date
By signing this form,I hereby certj that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ElYes or IDNo with 15A NCAC 02C.0100 or I5A 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
e
9.Total well depth below land surface: 62 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: 50 (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.) i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail ServicetCenter,Raleigh,NC 27699-1636
13a.Yield(gpm)_ _ Method of test BOW 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: [ hrl- 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