GW1--04426_Well Construction - GW1_20240723

II 11111.1%01111
WELL CONSTRUCTION RECORD(GW-1) / For Internal Use Only:
1.Well Contractor Information: P/ -►W
S ti-4 ley Se'�' R. 14.WATER ZONES
Well Contractor Name FROM _ TO DESCRIPTION
a J S 5 A Isg ft. 20 ft. 5
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 MATERIAL
0 ft. ' /L� f�] ft. e y in. SDt1��/ fit,
2.Well Construction Permit#:Company Name I I I v` (p 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.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural oMunicipal/Public 0 it. ft. in.
Geothermal(Heating/Cooling Supply) oResidential Water Supply(single) ft. ft in.
InIndustrial/Commercial DResidential Water Supply(shared) 10.GROUT
l',Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOK T
Non-Water Supply Well: 0 ft. A° ft. Ale- pIv eav, (_23V bjs)
Monitoring 13Recovery ft. ft. a✓✓��///
Injection Well:
ft. ft.
Aquifer Recharge OGrotmdwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery ElSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
[]Aquifer Test []StormwaterDrainage ft, ft.
0Experimental Technology []Subsidence Control ft. ft.
OGeothermal(Closed Loop) El Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soit/rock type,grain size,etc.)
@Geothermal(Heating/Cooling Return) {]Other(explain under#21 Remarks) ft. R.
�1 ° / ieut ci`�`1
4.Date Well(s)Completed: y.2 9-12g Well ID# / ft. y.. ft. •69,e,u.4n� ,J/
5a.Well Location: 7 a ft. S's ft. d��/ca tun C/)14,�/ /1 r w�
Brandt Construction Group LLC/Brandon Beckham 1.5 ft. /�/Q ft- ! 2 Aviv ne d Roe k -4 az i -e4
Facility/Owner Name Facility ID#(if applicable) `JI o ft. i2, ft- -�QT�/ut_ 4-S de�__ 1 /1 a mo+
2601 Forbes Rd., Gastonia, NC 28056 T it. e�! l9
Physical Address,City,and Zip ft. ft.
Gaston 21.REMARKS �. +_ •r +i 1,_
County Parcel Identification No.(PIN) fJL 2 :. 2024
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -
(if well field,one lat/long is sufficient) 22,Ce ' 'on: ....fat il ii'r<nair g:nt UO
jido IYA:Ci3C4
N W r v� -a�-��y
6.Is(are)the well(s)Ox Permanent or Temporary Si a of Certified Contractor ate
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: OYes or XlNo with/5A 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 1)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 details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: A-'4 (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: 141 (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
13a.Yield(gpm) 15 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: -S DZ 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