GW1-2023-02175_Well Construction - GW1_20230306

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
�1 z C.V�o 14.WATER ZONES
Well Contractor Name ^ _ J FROM TO DESCRIPTION
L ft.
15 1111123 � ft. 1%�ft. ,
NC Well Contractor Certification Number 9���`
15.OUTER CASING(for multi-cased wells)OR LINER it a Gble
James Darby Well Drilling, LLC FROM TO DIAMETER THICKNESS caMATERIAL
o ft. in. �`��� VIC__
Company Name /
14028 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.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipaVPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) XOResidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. 'lO ft. -P?t�lfdytr �/tl3ct3V
Monitoring E]Recovcry
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
_
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) DTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) FlOther(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soil/rock G rain size,etc.)
r b ft.
4.Date Well(s)Completed:1 -5--�3 Well ID# lJ ft JIY�
5a.Well Location:
Rykar Homes ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. s" �� � • -„
131 Bradley Trail Gastonia, NC 28056 ft. ft. p a ; ,.,,
Physical Address,City,and Zip ft. ft. v
Gaston 21.REMARKS
uu
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
N W
6.Is(are)the weD(s) X Permanent or Temporary Sign re of Certified Well Contractor 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: [3Yes or E)No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If tubs 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: I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �0 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3@200'and 2@I00) construction to the following:
10.Static water level below top of casing: 3 (ft.) 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 Injection 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) ✓ C) Method of test: Blow 24c.For Water Supply&Iniection Wells: In addition to sending the form to
4, the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: C1J�l— 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 Revised 2-22-2016