GW1--04370_Well Construction - GW1_20240723

I
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Well Contractor Information:
CI
(D/I Z/20
,s-44-n i Selidea, 14.WATER ZONES
Wet Contractor Name
FROM TO DESCRIPTION
I 5 A- fig
n. //.5 ft. 14thehiln,e
ft. 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 DIAMF. ER THICKNESS MATERIAL
0 H. Li y ft. 6, i n. .SD e-2l Pi/C.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 14309 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) H• ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 0Municipa1Public ‘/ ft. 4:,5 ft. [f/ in. 0 2. Se*qv Pu t
DGeothennal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. ' in.
()Industrial/Commercial DResidential Water Supply(shared) is.GROUT
11 Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: a ft. 2( ft 4,le- NU, P)Q 2
aMonitoring Recovery ft. ft. `
Injection Well: —
ft. ft.
Aquifer Recharge 0Groundwater Remediation
—
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery ❑I Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
QAquifer Test DStormwater Drainage
ft. ft.
Experimental Technology DISubsidence Control ft. ft.
DGeothermal(Closed Loop) 0Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks)
0 n. 1 $ ft. ReL C �
4.Date Well(s)Completed: .Z i— Well II)# ' gm '3� R L?a,d t✓Al. C.14- ,
5a.Well Location: 3 4 ft. c
• I o 2 ft. a ei:,►4i't.-I-e-
Adolfo Illescas a ft. + - •-••.•VL.d�.f
Facility Owner Name Facility ID#(if applicable) ft. ft. JUL 2 - 2024
1030 Riddle Rd ft. ft.
Physical Address,City,and Zip ft. f[. if ) �'..' tJ>"1
Gaston 21.REMARKS ar. 3 V._
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certificatio •
N W ,/ .,0S,23-2025,
6.Is the wells Permanent or Te Si o citified Well Contrar Date
Is(are)
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: DYes or gNo with ISA 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-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: / O 2 (ft) 24a. For MI 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: ../.. (ft.) Division of Water Resources,Information Processing Unit,
If miter level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 1(t I/I4 (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) 38 slethod 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: -7 a's-- completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016