GW1--04423_Well Construction - GW1_20240723

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: Sell/ #7/4/9..I
Stern/ey Se-rice. 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
t;• 1 5 A /Rft. 110 ft. NOhYIC 4. Ito e,k
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 DIAMETER THICKNESS MATERIALA
Oft. CI
n•, ft. 6 8 in. St)a.2' P V`,
Company Name
2.Well Construction Permit#: L
^ 9(0 16.INNER CASING OR TUBING(geothermal closed-loop)
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. -
Water SupplyWell:
17.SCREEN
W FROM TO DI:&ME IT SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public 0 ft. ft. in.
OGeothermal(Heating/Cooling Supply) xDResidential Water Supply(single) ft. ft. in.
0lndustrial/Commercial D Residential Water Supply(shared) 18 CROI,l
irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: D ft. a 0 ft. /4/r "VI a
0Moni tor ing D 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 D 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,soil/rock type,grain size,etc.)
OGeothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) 6 ft. ri ft. RC d e i,447
4.Date Well(s)Completed: b I2.a02Y Well ID# ft. /G ft. 13ao )n elm/ 4-.C4KJ.-l+-r l X
5a.Well Location: We I'4 j 110 ft. 85 ft. SO Pr Slt+t d. s-6tP-
Rick Hampton PS ft. ja# ft. 5,440,94 tt'-e _
Facility/Owner Name Facility ID#(if applicable) ft. ft. )
141 Robindale Rd., Gastonia, NC 28056 ft. ft.
24
Physical Address,City,and Zip ft. ft. ) 2 ," 1
Gaston 21.REMARKS
trdt;:,..t.r:. ,: ? r.-."a. .t',west
County Parcel Identification No.(PIN) D'FrC.s SCia's
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certifica /
N W X I,', ., 6-/2-Zy
X Tem re Si o C ified Well Con for '� ' Dui,:
6.Is(are)the well(s)DPermanent or po ry
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: °Yes or XDNo with 1SA NCAC 02C.0100 or/SA 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
n
9.Total well depth below land surface: /o� 9- (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@100) construction to the following:
10.Static water level below top of casing: /5 (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 SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
I 3a.Yield(gpm) 14 D 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
13h.Disinfection type: HTH Amount: 3 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