GW1--04371_Well Construction - GW1_20240723

WELL CONSTRUCTION RECORD(GW-1) o Internal se Only:
1.Well Contractor Information:
Soh 1 ey S eTz-e,2 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name�j
j1 S /0(11 10 2 ft 4,Mdi4urC.Q
1 tett. l'Ta ft. t. t
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
James Darby Well Drilling, LLC FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. yet ft. & LS' in. Sxjg_yJ pvc
14175 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. ill.
3.Well Use(check well use): It. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
°Agricultural pMunicipaVPublic I ft. i 2..1 fL u in. -t 2 s.eit,,,41 Puce
Geothermal(Heating/Cooling Supply) [Residential Water Supply(single) h, ft. ` in. '
°Industrial/Commercial D Residential Water Supply(shared) 18.GROUT
11 Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 6 ft. 2.1 R' A,le KKKU? ed U rt.
0Monitoring Recovery ft. ft.
injection Well: ft. ft.
°Aquifer Recharge °Groundwater Remediation _
19.SAND/GRAVEL PACK(if applicable)
EDAquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
°Aquifer Test °Stormwater Drainage ft. ft.
°Experimental Technology °Subsidence Control ft. ft.
°Geothermal(Closed Loop) IDTracer 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) V ft. 2 ( ft. L1 l
J 4.Date Well(s)Completed: _l it"21 Well ID#. 2( ft. 4 1 ft. /1 La W n e`ke,y
l�
5a.Well Location: (4 ( ft. 260 ft. A o� 1.-Lr
Radotz,Brad ft. ftft. ft.
t C '
Facility/Owner Name Facility ID#(if applicable)
438 Upper Stanley Rd. Stanley NC 28164 ft. ft. ' (!_ 2 , 2024
Physical Address,City,and Zip ft. ft.
21.REMARKS ..l t .rpnt0.,7 r
Gaston Wirs:sf
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.Certific ' n:
N W - 6-.4cl 2'y
6.Is(are)the well(s)OPermanent or OTemporary Signs of Certified Wel ontractor 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: DYes or )No with 1SA NCAC 02C.0100 or 1SA 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: -.0O (R-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2Qa 100') construction to the following:
10.Static water level below top of casing: 17 (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.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLYt WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636 J 13a.Yield(gpm) s Method of test: Blow 24c.For Water Supply&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: di G'a- 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