GW1--03240_Well Construction - GW1_20240528

6�'/ WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: ka_
Jam cd fic,1 I C I4:WATEIt ZONES
FROM TO DESCRIPTION
Well Contractor Name Jft. 1/J r ft l� (�
114to _ A / `�/•�J 1'i J A Yt�
ft. ft
IZ
NC Well Contractor Certification Number :15.OUTER CASING(for multi-cased wells)ORLINER(if applicable) - -s
CPI
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
/� , .16.INNER CASING OR TUNING.(geitliermal closed-loop)
2.Well Construction Permit#: V g y l 1 V V FROM TO 4AMETER
(�. ArmCKNESs MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) `t,I ft. ']S ft. A1,3s. S de 2' love.
T R. J ft. in. Y
3.Well Use(check well use): _
Water Supply Well: ��SCREED.
PP Y FROM TO DIAME R SLOT .F TH7S MA
['Agricultural ❑MunicipaUPublic t ft ( in. `///
['Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft ft in•
❑Industrial/Commercial ❑Residential Water Supply(shared) 18. OUT
❑hrigation ['Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENits
4
TROD AMOUNT
Non-Water Supply Well: b ft. 9.1 ft. 9Lh 1`D3 6i t, 'ry 6,a,,j
❑Monitoring ['Recovery ft. ft `( "Mf
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
i 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ['Salinity Barrier FROM TO MATERII EMPLAC METHOD '
❑Aquifer Test ❑Stormwater Drainage t. ft. /
['Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets ff.necessary)
['Geothermal(Heating/Cooling Return) ['Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,solllrock type,grain size,etc.)
Date Well Started � -2� 11 �( v ft. ry 6 ft. Sci f
4.Date Well(s)Completed:4-2A-2'{ Well ID#�PJ''^�U 3 0 of` ft. _�11 it/ ft. t `��,� ✓rc7 rot K M�
5a.Well Location: Phone#: 3 3(, " 46 -071y2 al gift. .44, ft. _ ,r<y r01 Yct.1
D.,,,,j„,
(4J;, Arch(Jo/ `A 1(/ ft. SV I� ft. 1 e49)'f 1l' ��/✓t7 •Dti4✓ d
Facili caner Name K p VFacility ID#�(if applicable)( l qe� ft. ft.
14W 6g,Wi(056ora ,meaOIDt 1 ft. ft.
ft. ft.
Physical Address,Cy,y,and Zip
Iitz3 21.REMARKS
County Parcel Identification No.(PIN) r/
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: - MAY cJ S ?fl74
6-
(dwell field,one tat/long is sufficient) 22.Certification:
6.Is(are)the well(s):Xermanent or ❑Temporary Signature of Certified Well Contractor 'D/ate
n
By signing this form,I hereby cert fy then the well(s)was(were)consoucted in accordance with
7.Is this a repair to an existing well: ❑Yes or *o 1SA 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. W
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details: r
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.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: So a (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q200'and 2(41100') ^`
24a. For All Wells: Original form to Division of Water Resources (DWR), `N+
10.Static water level below top of casing: (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) A)
11.Borehole diameter: (in.)B It Off: 6` T
Program,1636 MSC,Raleigh,NC 27699-1636 -�1
7
12.Well construction method: A/I /1-4 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
['� 9 t Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) a1 Method of test: r/4jf A l f J�r 3 j
o i}{ Date Site Visited: S
70/o hth Site Visited
13b.Disinfection type: Amount: OZ By: AA /1
Fornr GW-1 �i North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
Price: 3Z,�, rt,,tTr-ucTe