GW1-2022-03125_Well Construction - GW1_20220307

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: `r`^
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14.WATER ZONES
Well Contractor Name FROM TO DESC ON
*� L ft• a���i/(/��
ft. % f
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased)wells OR LINER if a livable
James Darby Well Drilling LLC FROM To DIAMETER THICKNESS MATERIAL
Company Name
V ft. ft. / in.
/� � 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER TMCKNESS MATERIAL.
List allapplicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. ft in.
3.Well Use(check well use): tt. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER- SLOT SUE TMCICNESS MATERIAL
Agricultural [)Municipal/Public ft. ft. in
I Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM I TO r4ATERIAL EM L.ACEMENT METHOD&AMOUNT
Non-Water Supply Well: tt. Q ft. n /
Monitoring ID Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge [)Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
i Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
:)Aquifer Test DStormwater Drainage ft. ft.
:)Experimental Technology OSubsidence Control ft. ft.
I Geothermal(Closed Loop) DTracer 20.DRILLING LOG attach additional sheets if necessary)
,Geothermal(Heating/Cooling Return) r Other(explain under#21 Remarks) FROM TO DESCRI ON color,hardness soil/rockrain s' etc.
22 ft. '/ ft.
4: V'Date Well(s)Completed: Well w# ) ft. it. !i✓fl S`0
5a.Well Location: tt. tt. �Q �Oto/J7 •
Rykar Homes d ft. da rt.
Facility/Owner Name Facility ID#(if applicable) Q ft. V rr0 ft.
1382 Lot#3 High Shoals Rd., Lincolnton NC 28092 ft. ft.
Physical Address,City,and Zip ft. ft.
Lincoln 21.REMARKS r.
a..
County Parcel Identification No.(PIN) r+'
r
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certification: `022. .
n�''j,'d :3..: r,�, r
6.Is(are)the well(s) Permanent of Temporary
Sign a ofC ified Contracto r' te)�,i;{;>JhYT
By gning this form,I hereby c r fy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing weft: nYes or E)No with 15A NCAC 02C.0100 or 1 A 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. ..i
drilled: r SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface:,V (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:
j
10.Static water level below top of casing: / (fL) 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 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) / r I t Method of test: blow 24c.For Water Suauly&Infection Wells: In addition to sending the form to
e N the address(es) above, also submit'one copy of this form within 30 days of
13b.'Disinfection type: HTH Amount: ?/ completion of well construction to;the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources 1 Revised 2-22-2016