GW1-2021-03655_Well Construction - GW1_20210823

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1./Well Contractor Information:
C/ i
Kw(I 4- �.N9�S 14.WATER ZONES r
✓ / FROM TO DESCRIPTION k
Well Contractor Name Fa 0 ft �.ft-
31�5 I ft. lq ft. "` M
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable
James Darby Well Drilling LLC FROM TO DIAMETER '.TffiCKNESS MATERIAL
o ft. (b\ ft. 611 in. rL
Company Name 16.INNER CASING OR TUBING eothermaI closed-loop)
2.Well Construction Permit#: 1`7 4 ,4 1 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 Supply Well: FROMCREE TO DIAMETER SLAT SIZE TRICKINESS MATERIAL
J Agricultural [3Municipal/Public 0 ft. ft. in.
I Geothermal(Heating/Cooling Supply) x�Residential Water Supply(single) ft.
J Industrial/Commercial 13Residential Water Supply(shared) 18.GROUT
_i Irri ation FROM TO MATERIAL E LACEMENT METHOD&AMOUNT
Non-Water Supply Well: (� ft ft e &vhk ra
1 Monitoring Recovery ft. &
Injection Well:
ft. ft.
Aquifer Recharge ]Groundwater Remediation
19.SAND/GRAVEL PACK if a livable
I Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
_I Aquifer Test �Stormwater Drainage
Experimental Technology OSubsidence Control ft. ft.
I Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) J Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiltrock type,grain size,etc.
O & ft.
4.Date Well(s)Completed: �- Z Well ID# lu ft gy & ;
5a.Well Location: �2 ft ft t/nu^ Spy
Rykar Homes &(k ft ewe".,
Facility/Owner Name Facility ID#(if applicable) 7X
ft• pZ(� ft' G /Ze L
511 Lakewood Drive, Gastonia 28056 ft. ft.
D u
Physical Address,City,and Zip ft. ft. t .
Gaston 21.REMARKS 11 11 r
County Parcel Identification No.(PIN) �U J
--'tor lira
"'xS1Ct�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: it ,;':- ,
(if well field,one lat4 /!��
ong is sufficient) 22.Ce 'tcation: ,l r� ©�,')�s¢CU
N W � 5-4 7'
6.Is(are)the well(s) o Permanent or Temporary Signature of Certified Well 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: 13Yes or Ei 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 ofthe 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: (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100) 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 YR (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
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) 0 Method of test: 3�0"J 24c.For Water Supply&Iniecttiion Wells: In addition to sending the form to
the address(es) above, also submit done copy of this form within 30 days of
13b.Disinfection type:��— Amount: completion of well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resource's Revised 2-22-2016