GW1-2022-03124_Well Construction - GW1_20220307

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.WelContractor Information: / /72
&LIeZl 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
/� A ft. G ft.
,ff� ft. ft. .rG G fe
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
James Darby Well Drilling LLC FROM To DIAMETER THIC[INESS/ MATERIAL
Company Name v
j ! 16.INNER CASINGOR INCTUB (geothermal closed-loop)
2.Well Construction Permit#: f/ FROM TO DIAMETER THICKNESS MATERIAI,
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. fL
3.Well Use(check well use): it. ft. in•
17.SCREEN
Water Supply Well: FROMFROM TO nDIAMETERSLOT SIZE THICKNESS MATERIAL
Agricultural Di Municipal/Public ft. ft.I Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft.
Industrial/Commercial Residential Water Supply(shared)
18.GROUT
j hTi ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 6 ft9.10 ft' 1,C
(-Monitoring QRecovery ft. ft.
Injection Well: ft. It.
Aquifer Recharge QGroundwater Remediation
��,, 19.SAND/GRAVEL PACK if applicable)
I Aquifer Storage and Recovery P_V Salinity Barrier FROM To I MATERIAL EMPLACEMENT METHOD
:)Aquifer Test OStormwater Drainage
ft, ft.
:)Experimental Technology Subsidence Control tt. ft.
RGeothermal(Closed Loop) O Tracer 20.DRILLING LOG attach additional sheets if necessary)
i Geothermal(Heating/Cooling Retum) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION color hardn soil/reck type.,grain size,etc.
ft. 1 ft. e r
4.Date Well(s)Completed:—��� Well ID# 3�I_3 ft. y ft.
W
Sa.Well Location: QWto
AI
Rykar Homes ft. ft. r rd 17 an s0
Facility/Owner Name Facility ID#(if applicable) ft. Q ft. /
1378 Lot#4 High Shoals Rd., Lincolnton NC 28092 ft. ft.
Physical Address,City,and Zip ft. ft.
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.Certification:
/ate
N W r �i . ��t;�r'
'AAA '3A.20.1
6.Is(are)the well(s)oPermanent or OTemporary Sign a of Ce fied Well Contractor
By s ing this form,I hereby certify tht: he well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [!Yes or G,No with 15A NCAC 01C.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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: —00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 a200'and 2@1001 construction to the following:
10.Static water level below top of casing: 0 (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 WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) /•f 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: 62 0 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 1
Revised 2-22-2016