GW1--03356_Well Construction - GW1_20230516

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well
Contractor Information:
„ -
---+`_— FROM I TO DESCRIPTION
Well Contractor Name 6 3ft A
P ft 3 e23
/7311. 17gft
NC Well Contractor Certification Number -15-OUTER CASING frii•:mniti=c`needzvells.ORLINER'ifs"livable
Yadkin Well Company, Inc. FROM To DLedETER THICKNESS MATERIAL
t•
Company Name ;16MMKCASING'ORTITBING' eotliei�alc]oieii=lo`6 - _ __ -
FROM TO DL&METFR THI
LI/,-,-Z �, C mEss A MATERIAL
2.Well Construction Permit ��#: � u in. /� /-
List all applicable well cornstnectiornpernnits(.e.UIC,County,State,Variance,etc.) ft. L 7 ft. 6'J' 6),/g �i/V �� �
3.WeB Use(check well use): It
!n• W4I aA .r&e ��
Water Supply Well: FROM I
TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipalTublic ft ft �•
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) fL ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) IB:GRtlbT -
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD AMOUNT
Non-Water Supply Well: ft
❑Monitoring ❑Recovery ft. ft
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation _19,S AND IGRAVELPACI{ tfs_ . �- _ 40
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I To I MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stomrwater Drainage it. ft
❑Experimental Technology El Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer 10?:DRIILh!7G'1uQG atthchadditibnnlsHeetsiineces _- - _ _
FROM I TO DESCRIPTION colar,hxrdnus,soillrock sizc,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other( lain under#21 Remarks) ft ft
Date Well Started — — � 6 Sa
4.Date Well(s)Completed: - 3 Wall M#AP 4,�, ft. '79 jg ft #"d A
5a.Well Location: Phone#:.` a,—L U-,TMQ 90 ". 3,22 ft ® ��
°ol ft ft �. y
Facility/Owner Name Facility ID#(if apphcable) ft. ft .�'�:�i �` l.. ¢..%
p ft ft I q
Physical Address,City,and Zip :"� °
pry � .Z1:RF.MARK4," ..._ ([154Vi 't .:..Soil °`:'':`1Cit_.'_4?_->,y'• l%i'i:
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 1 A 22.CertifreatiD :
N 2-
6.Is(are)the well(s): CKermanent or ❑Temporary ignahue of Certified Well Contractor Date �.
By signing thisfonn,I hereby certify that the wells)was(were)constructed in accordance with IC
7.Is this a repair to an existing well: ❑Yes or W. JSA NCAC 02C.0J00 or 15A NCAC 02C.0200 Well Construction Standards and that a copy q-�'
Ifthis is a repair,fill out,Mown well construction itformatidn and explain the nature of the ojthis 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. q�
drilled: 24.SUBMITTAL INSTRUCTIONS G�
9.Total well depth below land surface: 3,2 4� (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3@200'and 2©100� e
24a. For AU Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
if w'aier level is above casing,use'•+"
(, ) ® ��, �y,��� 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter:_(^o rn Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department ofthe county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producin0 over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611 '
13a.Yield(gpm) s✓ Method of test: i'tiU /71""
° � Date Site Visited:
13b.Disinfection type: 70�O lltil Amount: Oz Site Visited By: µn 0 c V
Fort GW-1 North Carolina Department of Environmental Quality-Division of WaterResources Revised 6-6-2018
Price:--- - GJ