GW1--00760_Well Construction - GW1_20240131

CORD (GW-11 \ For Internal Use Only:
,�vr�LL CONSTRUCTION RE ��
1.Well Contractor In�forAmation: \I La 1 ,v" 7� •__-_ ., .:._ .. ._i 3'
FROM TO DESCRIPTION 3
t.
p/ellContractor Name id r ft. I r+7
41 e� @! ®� %a ft en° ft 2®4'I e&
of a••licible)_._--_. .•-- lv
NC Well Contractor CertificabonNumber _15..Oi1TER EASING(f6Ym DL )()RIMER� s(s MAri tIIAsL9 a c
an Inc. FROM TO j in' a�A ` 8,1 Pvc, I
" 0 Yadkin Well Company, -� '-'1 ft I �ft � �.4� • Su"�tir°7.( -- .-� -- - :�
Company Name p y �p �g '_16i INNER CASING O&•.TUBINNIG,•' ermal do edd 1611. -..-__....
OR !5_' 2... FROM TO
ETER THICKNESS MATERIAL
L,Well Construction Permit#:19�3
�- ft, ft. in.
List all applicable well construction permits(i.e.WC,County,State,Variance,etc.) ft ft in.
3.'Well Use(check well use): - _ f_f ._.
sJ7zSC1 .- - —
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Water Supply Well: ft. in
- ❑Agticultural ❑M icipal/Public
ft.(residential Water Supply(single) ft, ft in. J
❑Geothermal(Heating/Cooling Supply) __ - . ._-_-
❑Industrial/Commercial ❑Residential Water Supply(shared) :i8.GROUT:: MATEItIAIyAOEnu NT METgoD&AMOUNT
FROM TO
❑In-Waon ❑Wells- 100,000 GPD ® ft
ry
[�Z.. ft f.�z' '� Pow' f3-.�(A.,'aech,'rS !d ;,
Non-Water SuPPIY WeII�. T ., --
-'• ft. ft
❑Monitoring ,_ "__ ❑Recover
•
' ft ft
Injection Well: ( - • .
����'' _
BAN 3 L1�3G oundwaterRemediation -
❑AquiferRechazge - 19:SANIIIGRAVEIIPACK MATERIAL F31 LAd�MENTMETHOD
❑SalinityBarrier FROM TO
❑Aquifer Storage and Recovery .-} :) -^�._ .��t4.,_ ft. ft I
❑A uifer Test ;:1"" • . 5tormwater Drainage
❑BxperimentalTechnology ❑Subsidence Controlft .� _
OTracer l 9 3 .20.DRII:TSNGLOG.a-ttaeli iidditionnl sheetsif necess: n size,etc
DGeothermal(Closed Loop) FROM TO DFSCFt1PTLON color,hardness,soillroek A.o
IIPolar
❑Geothermal(Heating/Cooling Return) ❑Other(explainund- . 1 Remarks) 0 ft ft. ,,�U , "
Date Well Started = �: + 60 ft re_ p9 �� 7' �! a9 �"^��°
I. 4.Date Weil(s)Completed,_"7-_73 :Well ID# '
Phone#: 3• •� � 6 p ft i' S ft �4la ; #t c1 b 'i • y�9 go S)
i•, 5a.Well Location: �— 7 ‘ ft. /®0 ft • 'hap-tc �`G ib t 51' ra -1 Ct:U' '7L�'i
4 el ( ft 4 tc; ft elk. J,y...' �. rci-a 4-
Facility ID#(if applicable) t
I.
i� Facility/O vnerName (,(5 Q ft Q^�.�-1•tt co l��h- / " d�E.iI�2
SAD �ie/�'�" atz� �cDc)n�/aMOMS Zt1 f° ScT �-u`k
IPhysical Addreess,City,and Zip VD r 21 REMARKS --
I County
ParcelldentificationNo.(PIN) .
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22. ertification: 9
(if well field one]at/long is sufficient) ` S ft�j ��` ` ,sa��
N
a.C---- --.--' W , trio/ m
/' Stfture of Certified Well Contractor
Date
6.IS(are)titewell(5): �Ifermanerit or ❑Tempora_ry� By slating this form,I hereby certi that the well(s)was(were)constructed in accordance with
well: ❑Yes or L�1Vo ISA NCAC 02C.11100 on ISANCAC 02C.0200 Well Construction Standards and that a copy
'],Is this a repair to an existing ofthis record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the 23.Site diagram or additional well details:
repair under#21 remarks section or on The back of this form.
You may use the back this page to provide additional well constructions yfnecessary.
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same (add'See Over in Remarks Box).You may also attach additional pages construction,only 1 GW�is needed. Indicate TOTAL NUMBER of wells 24.SUBNIITTAL INSTRUCTIONS
drilled: •
9.Total well depth
d depth below land surface: a (ft) Submit this GW-1 within 30 days of well completion per the following:
i For multiple wells list all depths if different(example-3©210'and 2Q100') 24a. For All Wells: OLigiaal form to Division of Water Resources (DWR),
1
o0 (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
1 10.Static-water level below top of casing:
Ifwater levelection Control(IUC)
itis diameter:above casing,use 4 24b,For Injection Wells:Copy to DWR,Underground Inj
1.Borehole (in•)Blt Off: v Program,1636 MSC,Raleigh,NC 27699-1636
a s <D 4' 24c.For Water Su I and O en-Loo Geothermal Return Wells:Copy to the !
12.Well construction method: cat,environmental health department of the county where installed
(le.auger,rotary,cable,direct push,etc.) �
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells raducin over 100 000 GPD:Copy to DWR,CCPCUA
C 27699-1611
Permit Program,1611 MSC,Raleigh,N
13a,Yield(gpm) t. Method of test: 0...t
Date Site Visited: '3''' . -�
13b.Disinfection type: 7_ huh Amount: Oz Site Visited By:
North Carolina De artment of Environmental Quality-Division of Water Resources
Revised 6-6-2018
Form GW-1
Price: —
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