GW1--03093_Well Construction - GW1_20240522

lea A ed coW 5113/a4 Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
5414ty1�y Se-r-x-toA 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
7/ ft. 72_ ft. < 3 S e
NC Well Contractor Certification Number I S.OUTER CASING(for multi-cased wells)OR LINER(itap licable)
James Darby Well Drilling, LLC FROM TO DIAMETER THICKNESS MATERIAL
Company Name ft. 5 s ft. G L� in. $b R-Al flee
14261 16.INNER CASING OR TUBING(geothermal closed-loop)
L
2.Well Construction Permit#' U
FROM TO DIAMETER THICKNESS MATER .
List all applicable well construction permits(i.e.UIC,County,Slate,Variance,etc.) ft. ft. in.
3.Well Use(check well use): R. ft. in.
17.SCREEN
Water Supply Well:
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public 0 ft. ft in.
OGeothermal(Heating/Cooling Supply) x)Residential Water Supply(single) It. ft, in.
0Industria1/Commercial D Residential Water Supply(shared) 18.GROUT
l'Irrigation FROM "r0 MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O It ,2 0 ft. nbie 4hi patrn.. a.5.
Monitoring ORecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
rnAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
[JAquifer Test OStormwater Drainage ft. ft.
DExperimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) ID Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
OGeothermal(Heating/Cooling Return) Other(explain under#21 Remarks) /•y�"
�D ft. /y ft. let% t "{' !
4.Date Well(s)Completed: 11-1*:-.2 y Well ID# IL.` ft. 30 ft. Qt2a-✓ n- C`M.t,
5a.Well Location: 3 C ft. 37 ft. je.SA► Arse ay RIWei/
David Lowe 37 .ro 4-ftst Fme,ct 4actlL
Facility/Owner Name Facility ID#(if applicable) S0 !6 Z 3 1 ,4 '"" t! d_-, ,
168 Cook Sears Rd. Gastonia, NC 28056 ft. ft.
Physical Address,City,and Zip ft. ft. h I n Y 2 'i /r 7 i
Gaston 21.REMARKS
County Parcel Identification No.(PIN) .ir)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Ce i 'on:
N W ed / ' ) 41-/9-.2o2y
6.Is(are)the well(s)Ox Permanent or �ITemporary Si t Certified We onlractor 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: OYes or ©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 page to provide additional well site details or well
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: /6 1 (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(a3200'and 1 ajl00) construction to the following:
10.Static water level below top of casing: d"r 4'4- (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 (its.) 24b.For Iniection 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 Q
13a.Yield(gpm) i o Method of test: Blow 24c.For Water SUDDIV& Iniection 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: y o'7..... 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