GW1-2022-04450_Well Construction - GW1_20220502

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
o5eph R a;I4Towed14.WATER ZONES
TO IWell Contractor Name l FROM 1 iL DESCRH FIO�� G�G� 7
Ja 2i- / V`ft ft. ft. 1
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER rf a 6cable
James Darby Well Drilling LLC FROM To DIAMETER THICKNESs MATERIAL
O ft. 173 0 in. 2
Company Name fL (�/y` .! oG
y �%� 16.INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit#: J FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC.County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. fL in.
Water Supply Well: 17.SCREEN
plt y FROM TO DIAMETER' SLOT SIZE TMCE04ESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) XgResidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. a b it' Ol/r, R.
Monitoring []Recovery ft. ft!
Injection Well:
ft. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(ifs livable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) ❑ITracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRI ON color,hardness,soil/rock e, rain size,etc)
Geothem�al(Heating/Cooling Return) Other(explain under#21 Remarks) Q� ft. S-� ft.
1?e Oi
4.Date Weil(s)Completed: :J Well ID#j 3 S H ft. /J Cam& e ,41,0 of
5a.Well Location: r. (j ft. yG lQ 1w/ `lJl✓!7 6
Rykar Homes it' O ft- 67Vrivc ol�
Facility/Owner Name Facility ID#(if applicable) O ft. Q ft. / i Q
1366 Lot#7 High Shoals Rd., Lincolnton NC 28092 ft. ft. [�
Physical Address,City,and Zip ft. ft.
Lincoln 21.REMARKS
County Parcel Identification No.(PIN)
MAY 0 2
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22'.Certif ation:
sm, ATMN PROCES9UG VM a�
N W OR r
3 ,
6.Is(are)the well(s)OX Permanent or Temporary Si tore o Ccrti a ell Co ctor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or X)No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
if this is a repair,f rl 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
I
9.Total well depth below land surface:_ D� (ft-) 24a: For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 22@j100') construction to the following:
10.Static water level below top of casing: .7�- (ft) Division of Water Resources,Information Processing Unit,
1f water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 /4 (in.) 24b.For Iniection 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) QO (-PrA of test: blow 24c.For Water Suaaly&Iniection 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: (S LQ!� 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