GW1--03351_Well Construction - GW1_20230516

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
___./�L.� �s.1iJ�] f<1A:•WATER7.oNES°_`:�:f;;;S, -. .. .'. -_ - -
Well Contractor Name FROM TO DESCRIPTION /�pI4 tl�
4�lS/�1•�• �". SIDS ft- _fMxMAM ft. ft �s.G o
NC Well Contractor Certification Number
t:15:OUTER'CASIl`1G(156i':miilti-eas'ed'vieILt';OR`I,IINEER`:(if... _--- -
Yadkin Well Company, Inc. FROM TO DIAMETER THICENFSS _IIeabli:.
MATERIAL
ft. ft is
Company Name
I� y� 16c]OMCCASING'ORTUBING eotliermal'dused=lii'o'
2.Well Construction Permit#: ! d v ® FROM TO DIAMETER TEaCRNFSS MATERIAL y�
List all applicable well construction pe (L.e.UIC,County,State,Variance,etc) ft a ft in.
3.Well Use(check well use): ft. ft in.
Water Supply Well: FROM E - - - - -- - - - -
FRObI TO DLM2ETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public fti ft in.
❑Geothermal(Heating/Cooling Supply) Aesidential Water Supply(single) ft ft. in
❑Industrial/Commercial ❑Residential Water Supply(shared) —
18:GROUT
01trigation ❑Wells>100,000GPD FROM I TO MATERIAL EMPLACEACMTMETHOD&AMOUNT
Non-Water Supply Well: Q ft. 35 ft chltq 9 rdw
❑Monitoring ❑Recovery ft ft
Injection Well:
ft. ft
❑Aquifer Recharge ❑Groundwater Remediation _
119.SA1W/GRAVFJI PACK•if:a"licuble'. . - _-
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATFRIAL 1WLAC rv=METHOD
❑Aquifer Test ❑Stomrwater Drainage ft. ft
❑ExperimentalTechnology ❑Subsidence Control ft ft
El Geothermal(Closed Loop) ❑Tracer 120.DRI7CMGI:OG >ittacliadditioniilslieels'ifneeess _
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DEscRlprroN color,hardarss,sotUrock S etc
Date Well Started - 9- ft.
—
4.Date Well(s)Completed: '�.e �Well ID# �e ' 7 ft. ft. ri'
5a.Well Location: Phone#:�( t W-SJX EMS 5 3-S f ft nef �y,1Oyy
a y �G oyt >� /`ter! dl r�/1s :'j M r� ft. ft. eJCj� +
Fac&yloAerfiame Facility ID# if applicable) R' ft c�''Y
ft. ft
Physical Address,City,and Zip ���.��I9 9 L •Sf' ft ft M AY I
/ S, r�
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field brie Iattlong is sufficient) (,( py 22.Certification: l a
iA 1;
6.Is(are)the well(s): Permanent or ❑Temporary SignatureofC a ell Contractor Date
By signing thisform,I hereby certify'that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or Po ISA NCAC 02C.0100 or lSA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under*21 remarks section or on the back of this farm.
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 construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: L 24.SUBrv=AL INSTRUCTIONS
9.Total well depth below land surface: (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifd8erent(example-3(a3200'and 2®100D
10.Static water level below top of casing: 0o® 24a. For All Wells- Original form to Division of Water Resources (DWR),
(ft,) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
IJwater•level is above casing,use"+" pq.Cy'
f ter Borehole diameter: l!w (!-.)Bit Off: •7 O / 24b.For Injection Wells: Copy to DWR Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: m'i'14 p^J 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(ie.auger,rotary,cable,direct push,etc.) r county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: Q;Y'
Date Site Visited: LP
13b.Disinfection type: 70 o�o htll Amount: Site OZ Site Visited By: J a n
Form GW-1 _ North Carolina Department ofEnvironmentat Quality-Division of Water Resources Revised 6-6-2018
Price: � '�