GW1--04429_Well Construction - GW1_20240723

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
24 tosionoiamor
1.Well Contractor Information: ` t 1 fl
24
•--S-54-4 ley S',el zea. 14.WATER TONES
Well Contractor Name FROM TO DESCRIPTION
P. gs A 345 " 37 fL �itw€4-trito-s
ft. ft.
NC Well Contractor Certification Number 15.OUTERCASING(fir taulti-abed web)OR LINER(if )
James Darby Well Drilling, LLC ,FROM TO DIAMETER THICKNESS MATERIAL. .
0 ft. .1. &ft. CP 9 io. S DiX'2i / ✓_
Company Name
14282 16.INNER CASING OR TUBING(geothermal clmed-Ioap) - .
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County,State, Variance,etc.) ft. ft. is
3.Well Use(check well use): ft ft in.
17.SCREEN
Water SupplyWell:
FROM TO DIAMETER SLOT SITE THICKNESS MATERIAL
Agricultural 0Municipal/Public ft. ft. in.
OGeothennal(Heating/Cooling Supply) 13Residential Water Supply(single) ft. ft. in.
0 Industrial/Commercial DResidettial Water Supply(shared) 18.GRo rr
1 Irrigation FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 17 ft- ;O ft. Ad. pileet irJdiz
°Monitoring DRecovery ft. ft.
Injection Well: ft. ft -
DAquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK(if app able)
0 Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test DStormwater Drainage ft. ft.
DExperimental Technology DSubsidence Control ft. ft.
(jGeothermal(Closed Loop) Tracer 20.DRILLINGLOG(attach*dadaist-sheets ifaccessary).
Gmal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM f TO ft. DESCRIPTION(color,loudness,aalur.et type,gale size etc.)
eother
6 Re.-d- e
4.Date Well(s)Completed: Well IDti �Sj ft. 5 ft- R� fee
f5 5a.Well Location: & yD 2-fL di J4'"• 'e
Linda Garrison ft ft. � • - '
6 . '
Facility/Owner Name Facility ID#(if applicable)
ft. ft. t a.. •.1'L... ir 7.�1
2920 Forbes Rd. Gastonia, NC 28056 ft. ft. JUL 2 ?0?4
Physical Address,City,and Zip ft. ft Ili -4. •4 ,t yam,_ ,.
Gaston 21.RE.MAR_KS • -ow,:
County Parcel Identification No.(PIN)
fib.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Ce r �.1,,.
N W ff. .' i4:0t. 6-.77-.?oz
6.Is(are)the well(s)0Permanent or (Temporary Signa= ofCertifi ell Contractor• 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 1 SA NCAC 02C.0100 or ISA 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: y0a (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths 4-different(example-3(4200'and 2@I00') construction to the following:
10.Static water level below top of casing: 0 (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) Jo D Method of test: Blow 24c.For Water Supply&Injection Wells: In addition to sending the form to
v the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: Q D Z completion of well construction to the county health department of the county
where constructed.
Form CW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016