GW1--07615_Well Construction - GW1_20231120

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-i. .'t.CONSTRUCTION RECORD (GW-1) For Internal Use Only: •p
v �- ell Contractor Inform�atiioln:
�' Gatti ) ' dU 1‘:15. s;la iwATr zoNEs__....._ ::r. a:: .. u_.t. '�
Well Contractor Name ,FROM TO ,DESCRIPTION
g-� dri ft. ®El' ft /e- f il-
316° ft• 31 a-' it 3 1.
NC Well Contractor Certification Number
:035:OUTER CASING(ftiYuiiulti=c`ased )•:ORL NF2R. f iipplic 0316)1 V: -,-
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name •("11•
�+ •216:INNERCASINGOR TUBING(geutliermerclo'riniiop)7 `-'._'�_'2- .
2.Well Construction Permit#: 3 39®W C FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County /,State,Variance,etc.) +f ft. ys' ft., (�r/)-s'n• 4)ri-'d- Pkc
3.Well Use(check well use): ft. it in.
1 Well: :13.SCREEkl-... '_.-,---_- - Ty___ - --F _-' -.__ ,_:--_i`,
Water Supply-. FROM TO DIAMETER SLOT SIZE THICKNESS_ MATERIAL
❑Agricultural ❑Municipal/Public ft. it. in.
0 Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft. in.
❑lndustriaVCommercial residential Water Supply(shared) -❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 9° ft (km. f
OMonitoring ❑Recovery 4/ ft. 2? ft 6'-50 grill t.)47.1 r el
Injection Well: ft. ft.
DAquifer Recharge .❑Groundwater Remediation
1:19:SAND/GRAVEL PAGR'(if:aliplicable)::' _ --_--- _._.._"-`_=.�'`.
DAquifer Storage and Recovery ❑Salinity Bather FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test ❑Stormwater Drainage ft. ft
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❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer L201DFIEMGI;OG(dtfiicli Additional sheen ii:neceuary)P1.7=:_.,--__. 1:.1_::
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,sail/rock type grain size,etc.)
Date Well Started 0 ft. 3LI ft. 3-411.%
4.Date Well(s)Completed: /I-)^"a01-y Well ID# 4 06 -3 4. it. t/; 'ft �i 1•' .Q.4.• Ser'+E' *xi e,-e y
Phone# /; p' ' /� . .
5a.Well Location: LL •z`d-3N O 8< 3 • ft. ft � 9a•
T f� , ft. ft. '^
CAS 41 A barIts. - .
ft. ft, ' r tz'.`,",_:Ft•,,ii J^ r.:i ,)
Facilityhoar Name Facility lD#(if applicable) ,
1*f: Do••ge. �p��r ft. it . NOV 9, 9.2023
Physical Address,City,and Zip ft. ft n^
® U?,y REVIARICsi ,...._•_..____ _. t t
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: .
(if well field,one lat/long is sufficient) 22.Certification:
g 12e/Va N 8117,1745 G W s d, i1- -?(
6.Is(are)the well(s):permanent or ❑Temporary Si a of C Well Con ctor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: [Wes orro ISA NCAC 02C.0100 or ISA 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 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 construction info
construction,only 1 GW 1 is eded. Indicate TOTALNU NUMBER of wells , (add'See Over'in Remarks Box).You may also attach additional pages if necessary. r
drilled: i a 24.SUBMITTAL INSTRUCTIONS �)
9.Total well depth below land surface: (ft.) Submit this GW 1 within 30 days of well completion per the following:
For multiple well list all depths f digerent(example-3(4200'and 2QI00)
CIO., (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"1-.7)
p �g 24b.For Injection'Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in•)Blt Off: Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: .V / 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the 6'
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA 03
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: �b �'
o / Date Site Visited: 3.4 123
13b.Disinfection type: 70�c huh Amount: / E0 0z . Site Visited By: Vie I 1
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FormGW-I A i______ __a,q�e_NortILe.rnl;o,-t�hutment of Environmental Quality-Division of Water Resources Revised 6-6-2018