GW1-2022-05461_Well Construction - GW1_20220603

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
PhI IeV14.WATER ZONES
� FROM TO DESCRIPTION
Well Contractor Name D ft. 01, FLe��
y w4 fL fL
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells RIM if a t*cable)
James Darby Well Drilling, LLC FROM TO DtAIV�TER THICIQYESS MATERIAL
fL / iG �in. [ fl
Company Name J
13894 16.INNER CASING OR TUBING 'eothermal closes-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County.State,Variance,etc.) It. fL in.
3.Well Use(check well use): % fL iu
Water Supply WeD: 17.SCREEN-
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. fL io
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) R. % in
I
]Industrial/Commercial DResidential Water Supply(shared) 18•GROUT
phrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: D tL O tL ���anr
Monitoring _'Recovery fL &
Injection Well: ft. fL
Aquifer Recharge Groundwater Remediation
19.SAND/GRAYEL'PACIC'ifa" livable "
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [)Stormwater Drainage ft. ft.
Experimental Technology [ISubsidence Control fL R.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) r3Other lain under#21 Remarks) I
FROM TO DFSCR ON eolor,hardness,seittrock in sim,etc
10 ft. fL C c
4.Date Well(s)Completed: Wen ID# rL I" 6t?w
5a.Well Location: GI Q
Rykar Homes rL rL
Facility/Owner Name Facility ID#(ifapplicable) ft. fLOe/
366 Meek Rd Dr. Gastonia, NC 28056 R. fL
Physical Address,City,and Zip ft. R.
Gaston 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I I U e3 2022
(if well field,one lat/long is sufficient) 22.Certification:
N W f rivtti.:�
wry, I
t„ e'
<;a
6.Is(are)the well(s)OPermanent or Temporary Si7igning
of Cc ficd We Conviftoy
to Da e
By this form,I herebyat the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or MNo wi h ISA NCAC 01C AI00 or I5A NCAC 02C.0200 Well Construction Standards and that a
Iflhis 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: ,WQ (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@I001 construction to the following:
10.Static water level below top of casing: 00 Division of Water Resources,Information Processing Unit,
Ifwater level is above casing use"+" 1617 Mail Service�Center,Raleigh,NC 27699-1617
11.Borehole diameter: s /4 (m.) 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
139.Yield(gpm)_�� Method of test: Blow 24c.For Water Supply&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: _ completion of well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016