GW1--04373_Well Construction - GW1_20240723

WELL CONSTRUCTION RECORD(GGW--,1) I 8/4
For Internal Use Only:
1.Well ContractorInformation: �'• `-. VI
CN(arlt ll ) ,�tid tS 14.WATER ZONES
VV" FROM TO DESCRIPTION
Well Contractor Name 10, ft. t2p ft. 36.rLytol
nu
2/5C 1 lib ft. I y7 ft. 367„,04.......„
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 3 ft. l1 ft. 6y�t in. �04�� ft,
14356 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#' FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well constructionpermits(i.e.UIC,County, etc.) ft. ft. in•
pp State,Variance,
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROM
REE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
a Agricultural ['Municipal/Public U ft• ft. in.
['Geothermal(Heating/Cooling Supply) x['Residential Water Supply(single) ft, ft, in.
['Industrial/Commercial ['Residential Water Supply(shared) 18.GROUT
',Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft.
f) ft. t/I.itlh t- i , ;re m
['Monitoring ['Recovery ft. ft. /
Injection Well: ft. ft.
Aquifer Recharge ['Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer 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) ['Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soiUrock type,grain size,etc.)
['Geothermal(Heating/Cooling Return) ['Other(explain under#21 Remarks) D ft. (,.2 ft. eed C/, _4.Date Well(s)Completed:7- /-.2.'( Well ID# ( ft. TZ--ft' '.\- _- s--(4t 1
5a.Well Location: .) 3 ft.
-P( ^ SI(
Dennis Arrendale St ft ft.. (IR ft. bnnd., we0.-tk.tp lorl_
Facility/Owner Name Facility ID#(if applicable) (,r 9 ft. Jo ft. l K I/ D,4 L^
, '
302 Ridge Dr. Mt Holly, NC 28120 ft. it. ,.. f__
Physical Address,City,and Zip ft. ft. I(J 1� 2 '
Gaston 21.REMARKS J �� t
County Parcel Identification No.(PIN) OW . ^.�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W 71(. i24,,,t.----%_. •
6.Is(are)the well(s)Jt Permanent or ['Temporary St ahrre of Certified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ['Yes or @No 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 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: Q`0O t (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@I00) construction to the following:
10.Static water level below top of casing: (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 SUPPLYWELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
//
13a.Yield(gpm) ( 4 Method 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: ?XI I-- 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