GW1-2022-03122_Well Construction - GW1_20220307

WELL CONSTRUCTION RECORD(GW-1) '? For Internal Use Only:
1.Well Contractor Information: `
llgetDti G;
14.WATER ZONES
Well Contractor N me FiROM,r� TO DESCRIPTION
ft C r'FG Ute
/ ft. fL
NC Well Contractor Certification Number 15.OUTER CASING for tnulti-cased wells OR LINER if a ticable
James Darby Well Drilling LLC FROM To DLAMETER THICKNESS MATERIAL
Company Name
0 ft. D ft. I in.
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: I 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
J Agricultural E)Municipal/Public ft. ft, in.
I Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in,
3 Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
ft. '
i Monitoring DRecovery ft. ft.
Injection Well:
fL ft.
Aquifer Recharge []Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
I Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
I Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRI ON color,hard ess,soil/rock e, in size,etc.
Geothermal(IIeating/CooGng Return) [ Other(explain under#21 Remarks) 6 ft. ft.
4.Date Well(s)Completed: Well ID# � ) I ft. fL
5a.Well Location: ft. ft. soil rove
it. r
Rykar Homes 6 O ft__._f__-0_Lt/_ _�0._�✓�'I Q_r ____,__ .__
Facility/Owner Name Facility ID#(if applicable) 46 ft. 9 ft. ' 'r� r' s 501
1370 Lot#6 High Shoals Rd., Lincolnton NC 28092 ft• o ft. rq.,)17r.
Physical Address,City,and Zip ft. ft.
Lincoln 21.REMARKS MAR 0 7 207
County Parcel Identification No.(PIN) 4
O. nW'u cCSCVI�IffV
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: - --- - --- -- -- - -- "'" '
C
if well field,one lattlon sufficient l
g�is ) 22.Cer' cation: G
N W y 7J
4-q-91F
6.Is(are)the well(s)oPermanent or OTemporary ;yl?signing
ture of ertifi d Contract Da
this form.I hereby lift'that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E)Yes or E)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 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: t SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:_ 10 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths i(different(example-3@200'and 2@1001 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) �3�J�/�I Method of test: blow 24c.For Water Supply&Iniection Wells: In addition to sending the form to
fJ the address(es) above, also submit one copy of this form within'30 days of
13b.Disinfection type: HTH Amount: -d t)-2i 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 I'i Revised 2= M016