GW1--04407_Well Construction - GW1_20230710

.�1ELL CONSTRUCTION RECORD (GW-11 For Internal Use Only:
1.Well Contractor Information:
J't - I4t7 L. C U0V i ,14WATER-ZONES': :: • -
FROM TO DESCRIPTION
Well Contractor Name
` ry y ��� ft.ft.
f ft t
J CC ft. ft Q m
NC Well Contractor Certification Number 115:OUTER CASING(fo"r mold-cased:wells)OR IINER•(if.'ap'licalile) .-' D3
Yadkin Well Company, Inc. PROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in. "y
Company Name _
f y,✓ rr '.'16.1NNER CASING:ORTQBING:(geothermal closed=loop)- _
2.Well Construction Permit II: / Ci b 3 5 FROM TO DIAMETER THICKNESS MATERIAL ^S
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in. �./7
3.Well Use(check well use): ft. ft. in.
Water Supply Well: EL-L7:SCRER.11; ':` :. _ .... _ • ---- - - --- • .:FROM TO DIAMETER SLOT SIZE THICKNESS - MATERIAL 111
`
['Agricultural ❑Municipal/Public ft ft. in. C-
❑Geothermal(Heating/Cooling Supply) 2esidential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) - • - -
• 28:GROUT::!;.:- - -. _ .. ..
['Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft
❑Monitoring ❑Recovery ft. ft
Injection Well: ft ft
❑Aquifer Recharge .❑Groundwater Remediation
1.:19:SAND/GRAVEL;PACK(if
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft
DExperimental Technology OSubsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer -20.DRI)_.T;INGLOG(attachadditionalsheetsifnecemsary) ._ _---_ . .-
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) -FROM TO DESCRIPTION(color,hardness,soil/rock type grain size,etc)
vr
Date Well Started 6..4 -- 7' ft, ft.
4.Date Well(s)Completed: o•-•8-, .may Well ID# �(r-
6 3 V _a3 ft. ®? ft. � Fr`�„ i.�e-
Phone#: 3156'.)Iii-/ � ft. ft .J
5a.Well Location: l' : -i^°ti-r 7, ^^r'°. .C./] ft. ft i ,LL ,'t...r L..e V 1..... it
e-t' Faciity/Owner Name Facility ID#(if applicable) ft. ft l i J I` 1 f1 7 n 9) 0
Zg"Z /14 Idb®�� Ad ft ft
ft ,ft. IniOUTI;; . 1 -' -.F.AW4 ;) r..lJ
Physical Address,City(aid Zip/ ri4F^•:,i,1r-s
/ .11:R ALi IVYTCR- -- -
9`"q
County f G�J ��� Parcel Identification No.(PIN) . ' -e1 . ` ' 603® ��-�
5b.Latitude andlongitude in degrees/minutes/seconds or decimal degrees: ®ri 161 64 d -"
(if well field,one le/long is sufficient) 22.Certification:
a-A/tot,
.?`e. OGI 4 N F j ,,Zt,, ‘ y q w
6.Is(are)the well(s): Permanent or ❑Temporary Signature of C ed Well Contractor Date
xt
By signing this form,I hereby certify that the weC(;)w,r•;'tv..•e)constructedin accordance with
7.Is this a repair to an existing well: Yes or t 1No �e'.7*e le ISA NCAC 02C.0100 or 15A NCAC 02C.0200 li a?l r'ens.metion Standards and that a copy V"
If this is a repair,fill out known well constructs nt information and explain the nature of the of this record has been provided to the well owner.
repair under#2I remark section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-I Js needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITI'AL INSTRUCTIONS
9.Total well depth below land surface: irf-+/ (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@10
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 1 (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
/ 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: 1� (in.)Blt Off: c +t� Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: r b I-Q ti^>' 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 of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) X Method of test: 4✓
rP7 Permit Program,1611 MSC,Raleigh,NC 27699-1611
70%
n hth y�;� Date Site Visited: .'.26-.23 T 12
• 13b.Disinfection type:_ Amount: ,� Oz Site Visited Bji`_.'' 1/
(Al.M) - -
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
Price: 1 - -._.