GW1--06212_Well Construction - GW1_20230925

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: t,
1.Well Contractor Information: 1
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14.WATER ZONES
WeIlContmctorName FROM TO J DESCRIPTION
a I d$ A ft. /
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ft ft. 0 I,
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
James Darby Well Drilling, LLC FROM TO, DIAMETER THICKNESS MATERIAL
Company Name b ft. G,ft. //, -1'in.spa' 1 r v-
13995 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U/C,County,State,Variance,etc.) ft. ft. I in.
3.Well Use(check well use): ft. ft in.
Water Supply Well: FROM EN TO DIAMETER SLOT SIZE THICKNESS MATERIAL
®Agricultural 0Municipal/Public 0 ft• ft. in.
N Geothermal(Heating/Cooling Supply) (x Residential Water Supply(single) ft. ft. in. •
U Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
I Irrigation FROM TO MATERIAL , EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft* at tt. !44e_ 1'(o5 _ pO J n
it Monitoring IDRecovery ft. ft. I
Injection Well:
ft. ft.
ill Aquifer Recharge DGroundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
®*Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
I Aquifer Test L Stormwater Drainage ft• ft.
•
®Experimental Technology 0Subsidence Control ft. to
illi Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
ill Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION/� l (color,hardness,soil/rock type,grain size,etc.)
a f` ).Jt ft' /Sec+ dli
4.Date Well(s)Completed:53-.23 Well ID# o2�15 fc 8). ft- ,g n
5a.Well Location: F2ft• aU 3 ft' a 2 4 11t 4
Rykar Homes ft. ft. 4
Facility/Owner Name Facility ID#(if applicable) ft ft .'Z,`,t_,r 1'i •t,' ..,
105 Lighthouse Church Ln, Gastonia, NC 28056 ft. ft. ,, P
Physical Address,City,and Zip ft tt SE 2 !`xi U J
Gaston '�
21.REMARKS Iflii/in'��,;1 rf..,.,-�...:..;t� ?
County Parcel Identification No.(PIN) II `� taoa
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22•Ce • c ti n:
N W
t 4-1- 5 -3/--.2 o..2''''
6.Is(are)the well(s) Permanent or QlTemporary Signature of Certified Wel}�Contracto Date
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By signing this form,I hereby cent fy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: IjYes orlNo 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:
S.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 neeP‘sary.
drilled: SUBMITTAL INSTRUCTIONS'
9.Total well depth below land surface: Cro (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@200'and 2@100') construction to the following:
(,� IProcessing
-1 Z (ft) Division of Water Res 10.Static water level below top of casing: o urces,Information Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
''6 1/4
11.Borehole diameter: (in.) 246.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:
(Le.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) 5 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:.___,I. O y 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
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