GW1--03382_Well Construction - GW1_20230517

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
P l()A e_ V o C,.1n� 14.WATER ZONES
Well Contractor Name / FROM TO DESCRIPTION
�`S� F �—"d/ ,2 / ft. ft. /b.'0111
$/31/ z I LI ft. 4 Z ft. `/� qt \
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 MATE.R/IAL
© ft. ft. &y'& in. 5' v,2 I
Company Name
__ '"� 16.INNER CASING OR TUBING(geothermal closed-loop)
2 Well-Construction Pel'ihit#:y 7 / FROM To Dwnn,TER 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: FROMREE To DIAMETER SLOT SIZE THICKNESS MATERUL
Agricultural DMunicipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) .Residential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ;?o ft L�J7fl l�zi , �y7dki
Monitoring DRecovery ft. ft.
In ec jtion Well:
Aquif ft. ft.
er Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if a 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) DTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) FROM To DESCRIPTION color,hardness,soil/rock type,grain size,etc.
ft. G ft.
4.Date Well(s)Completed: c? /Q � Well ID# ft. 3 L ft. T Sol I
5a.Well Location: :i. -7_ft. 6— ft. • a"',<-,;' t �
Rykar Homes ft ft. (Rc�-I"eZO"-
Facility/Owner Name Facility ID#(if applicable) ft. t ft. � e_
1362 High Shoals Rd. Lincolnton, NC 28092 ft. ft.
Physical Address,City,and Zip ft. ft. F ,k
I t f 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Cfwell field,one lat/lon sufficient lr�.j;s4„C l i L•
g�is ) 22.Certification:
N W
6.Is(are)the well(s)oPermanent or Temporary Signature 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: Dyes or EJNo with 15A NCAC 02C.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 921 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 I 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: "1 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierenl(example-3 00'and 2@100') construction to the following:
10.Static water level below top of casing: 3S (ft) Division of Water Resources,Information Processing Unit,
lfwater 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) j 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: Id 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