GW1--04422_Well Construction - GW1_20240723

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WELL CONSTRUCTION RECORD(GW-1) . For Internal Use Only:
1.Well Contractor Information:
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Well Contractor Name J FROM TO DESCRIPTION
pZ c g 5 6%3 ' ray ft. AZ$4"ae. V
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it. 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 DIAMETER I THICKNESS MATERIAL
0 ft. GI r ft. 6, t� in. J Cp a-I i p ve
Company Name
14214 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.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) IDResidcntial Water Supply(single) ft, ft. in.
0Industrial/Cornmercial OResidential Water Supply(shared) 18.GROUT
I1lrrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 2.6
ft. }4o l e phi, pd tJIQ
aMonitoring QRecovery ft. ft.
Injection Well:
ft. ft.
0 Aquifer Recharge D Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery 01 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test []Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
OGeothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
OGeothennal(Heating/Cooling Return) []Other(explain under#21 Remarks)
D ft. a ft. ge4 c/
p l 6-y
4.Date Well(s)Completed: 3-2-34 Well ID# 0/ )- ft. q6 e, ft. /1(zQ 'Wrq p�„4 N
5a.Well Location: I t, ? ft. / 3 ft. fYi2�g1°7URc,Cd` Rlae K
Falls Boyce 93 ft. 90 3 ft. a R1ri+'-1-e-
Facility/Owner Name Facility ID#(if applicable) ft. ft. .•' j(•
132 Charity Ln Belmont NC 28012 ft. ft.
Physical Address,City,and Zip ft. ft. I I 2024
Gaston 21.REMARKS
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County Parcel Identification No.(PIN) - QJ_Cy 3C4-
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certif .lion:
N W
6.ls(are)the well(s)13Permanent or °Temporary Si.t.if
a of Certified W t 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: DYes 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
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9.Total well depth below land surface: ! a 3 (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'anndd22Q100') construction to the following:
10.Static water level below top of casing: 517 (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 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
13a.Yield(gpm) ! 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: I y 07.' 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