GW1-2022-05456_Well Construction - GW1_20220603

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: A
14.WATER ZONES t-
-t FROM TO I DESCRIPTION
Well Contractor Nam �7
31� � � I'R l ft r /
im
ft e
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a'licable
James Darby Well Drilling, LLC FROM TO DIAIYIETER THICKNESS MATERIAL
ft 10 ft in. a r
Company Name
16:INNER CASING OR TUBING `eothermal'closeaaoo"
13893 MATE
FROM TO DIAMETER THIC
2.Well Construction Permit#: THICKNESS MATE
List all applicable well construction permits 6.e.UIG County,State,Variance,etc.) ft ft is
3.Well Use(check well use): ft R
Water Su Well: 17.SCREEN
Supply FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public R. It. in.
71
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft in
_Industrial/Commercial Residential Water Supply(shared) 18.GROUT
fl1r.gatto. FROM TO MATERIAL EMPLAC METHOD.@ AMOUNT
Non-Water Supply Well: 0 f 6 ft //B/f L
Monitoring DRecovery tt &
Injection Well:
Aquifer Recharge []Groundwater Remediation
'19.SAND/GRAVEti PACK:ita iicable t
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft
Experimental Technology Subsidence Control ft. ft
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional.sheets if necessa
Geothermal(Heating/Cooting Return) _ Other(explain under#21 Remarks) FROM To DESCRIPTION ,hardness,sail/rackm eta
- ft It. If0/
4.Date Well(s)Completed: Well lD# fr' ra a
ft /414✓/7 O
ft ft.
5a.Well Location:
Rykar Homes qQ, f ft a
Facility/Owner Name Facility lD#(if applicable) ft y ft
1353 Wildflower Dr. Gastonia, NC 28056 k• ft.
Physical Address,City,and Zip ft. ft
Gaston �21.REMARKS R r r F
County Parcel Identification No.(PIN) `
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: F''`n n5
gar r,se•• ? ( c•Ql^ n i.
N W � I°i��:�dntiill��e'4A ��P,i� ,��
i
6.Is(are)the we11(s)OPermanent or OTemporary Si tune o rdfie-d Well Co ctor Da
signing this form,I here certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or ONo 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 details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: JV I (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: E
10.Static water level below top of casing: 00 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 Infection 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 SuaDty&Ieiecl on 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 3 M 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