GW1-2023-02151_Well Construction - GW1_20230306

Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3 I�E 29 ?.3 eft. ft �;OF
11
NC Well Contractor Certification Number �ft D 5- fA 11 :p`2
15.OUTER CASING for multi-cased elllls OR LINER if a licable
James Darby Well Drilling, LLC FROM TO DIAMETER THICKNESS MATERIAL
Company Name
'�� ' / 16.INNER CASING OR TUBING eothermal closed-loop)
.=Well-Construction:Eerlllit: :� q FRO51 To DIAMETER THICKNESS MATERIAL
/2
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) FL ft in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DL4METER SLOT SIZE THICKNESS MATERIAL
0Agricultural DMunicipal/Public 0 ft. fL in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
— hrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. I
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)_
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACFMI NT MEMOD
Aquifer Test [DStormwater Drainage ft. fa
Experimental Technology E3Subsidence Control ft. ft.
Geothermal(Closed Loop) [3Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating(Cooling Return) Other(explain under#21 Remarks) FROM To DESCRrnTI�ON/color,hardness soiUrock c rain size eta
ft. fL
4.Date Well(s)Completed:a"jb' � Well ID# I,/ ft. 3Q ft. —rqyt i5rc;i C
5a.Well Location: 7J ft. ft `l3viiza�5
Rykar Homes q �ft s�--ft• -R fp�WetA
Facility/Owner Name Facility ID#(if applicable) Z5)ft- to,) ft �J __- _ r-r ;; •,
1350 High Shoals Rd. Lincolnton, NC 28092 ft. ft.
Physical Address,City,and Zip ft. ft `e
Lincoln 21.REMARKS
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.Certifications:
N W
6.Is(are)the well(s)ox Permanent or Temporary S tuM of Certified Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: [DYes or )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 92I 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 I 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: / tf 00 24a. For All Wells: Submit this form within 30 days of completion of well
i•'or 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: 3(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 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 pWELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ! lJ Method of test: Blow 24c.For Water Supply&Infection 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: L^ U-,) 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