GW1-2022-04320_Well Construction - GW1_20220502

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
;12� Ph &/ty 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
y� ft.
�7•• I�I ft.
S14 ft- W ft-
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if applicable)
James Darby Well Drilling LLC FROM TO DIAMETER I THICKNESS I MATERIAL
O ft. ^it ft / r in. C�Q
Company Name + `
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: _ FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County.State, Variance,etc) ft. It. in.
3.Well Use(check well use): ft. ft. in•
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. tt. in.
Geothermal(Heating/Cooling Supply) XOResidential Water Supply(single) tt. ft in•
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irri ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft '270, ft. �j AIr
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(d applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage
Experimental Technology subsidence Control
Geothermal(Closed Loop) DTracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soillrock e, rain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#2] Remarks)
ft. pod S �
4.Date Well(s)Completed: Well ID# ft. o ft. 1 f d
ft fL .fAdl
5a.Well Location:
Rykar Homes ft. a fL
Facility/Owner Name Facility ID#(if applicable) ft, ft.
4729 Bud Wilson Rd., Gastonia NC 28056 ft. ft.
Physical Address,City,and Zip ft. ft.
Gaston 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.Certification: Du-1 agmTMY
N
6.Is(are)the well(s) 7oC Permanent or OTemporary r� ature fCcrti Well o ctor D
y aigning Ihls form,1 here certifyWa
that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or E)No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ijthis is a repair,ill 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- r ✓'Y2— (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(a,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 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) ..)D ` 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: 7 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