GW1-2022-03083_Well Construction - GW1_20220307

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: �7
.5 eph &1 'y Qr'/ 14.WATER ZONES
Well Contractor Name / FROM TO / DESCRIPTION
5116 ft-
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if app'cable)
James Darby Well Drilling LLC FROM I TO DIAMETER T THICKNESS MATERIAL
ft. ,• /)ft. in. .5
Company Name V
16.INNER CASING OR TUBING(geothermal closed-too
2.Well Construction Permit#: 13 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. fL in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
i Agricultural DMunicipal/Public ft. ft. in.
I Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
IndustriallCommercial Residential Water Supply(shared) 18.GROUT
Ir[i ation FROM I TO MATERIAL EM LACEMENT METHOD&AMOUNT
Non-Water Supply Well: 6
ft' a 0 ft. do s
Monitoring ❑Recovery R, ft. OAS
Injection Well: ft. ft.
3 Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK ifapplicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage
Experimental Technology D Subsidence Control
I Geothermal(Closed Loop) DTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) (- Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness soil/rock a rain size,etc
^ 2 ft. ft.
4.Date Well(s)Completed: d Well>I1# 3 tt. ft. i
5a.Well Location: ft. ft. C tall
Rykar Homes ft' ft. / 00
Facility/Owner Name Facility ID#(ifapplicable) ' ft. ft. r O
1374 Lot#5 High Shoals Rd., Lincolnton NC 28092 t. ft. r-W
Physical Address,City,and Zip ft. ft. 7._"
. .. .+..n ,Aso,011 21.REMARKS
Ci
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: t
(ifwell field one lat(long is sufficient) 22 Ce[tifi lion: DAY 1I tl. Qi ttPv j��, (7�llty I
N W
6.Is(are)the well(s)OR Permanent or DTemporary Sign t
re o e ed a ontractor Da
By igning t form,I hereby certi t t the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or E)No with I SA NCAC 02C.0100 or/SA Min; .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#11 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: '�Ji��11 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: c2 9;L (fL) 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: ft) Division of Water Resources,Information Processing Unit,
Ifwater 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: (� f' 5 completion of well construction;to I 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