GW1--00313_Well Construction - GW1_20240112

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.
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Contractor Information:
1`l11air 1;C- ,bICiHol5 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
\t JV✓ 1 J--iLxq 15,ft. 'ram,(� ft. rooe
NC Well Contractor Certification Number /(13 )z ,b t ft. i Jfl.)-ft. )(V
ol
15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
James Darby Well Drilling, LLC FROM TO DIAMETER THICKNESS MATERIAL
0 ft. i ii-1I ft. (.9,IN in. SPt� -�.
;e Pvt..
Company Name ll
14140 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.
Water Supply Well: FROM SCREENTO DIAMETER SLOT SIZE THICKNESS MATERIAL
Ni Agricultural DMunicipal/Public ft. ft. in.
•Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
NI Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
I Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: J ft. ft. 1 /6v te_.L ?v rx;i e
®iMonitoring (Recovery ft. ft.
Injection Well: ft. ft.
NiAquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
NiAquifer Storage and Recovery QlSalinityBarrier FROM TO MATERIAL EMPLACEMENT METHOD
NI Aquifer Test IJStormwater Drainage ft. ft.
ii Experimental Technology D Subsidence Control ft. ft.
*Geothermal(Closed Loop) I Tracer 20.DRILLING LOG(attach additional sheets if necessary)
_ FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ;1 ft. `7.._ ft _ 1 t(,,._,
4.Date Well(s)Completed: 1 l-/v-?' Well ID# 'Vjt• Lj(5ft. .. �Oi,
5a.Well Location: Li-7ft. Q)5--ft. 'e msStsd it
Kimberly Bundy 85 ft. l 1 cft. --vvv' 3 ,. leoc.L
Facility/Owner Name Facility ID#(if applicable) 119-- ft. /37 ft. i5elmn_ Uv 624,‘,.,Q- /ice
No#yet Freedom Mill Rd. Gastonia, NC 28052 1 -7t• 'so ft. L a ,fie^r
Physical Address,City,and Zip ft. ft. ' 6 '+e�, e t tr Li
Gaston 21.REMARKS N{p 1 `2 202
T
County Parcel Identification No.(PIN) JAN 1li
In c;rilaticn PfC.,.,53i41•115 LIAR
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: C 30G
(if well field,one lat/long is sufficient) 22.Certific It-
N W < -7-3
6.Is(are)the wells)X Permanent or QlTemporary 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: 1:11Yes or DNo 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 h formation 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 details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: ( SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: oO (f(-) 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: LrVQ (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) Method of test: Blow 24c.For Water Supply&Infection 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: I 0 completion of well construction to 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