GW1--03242_Well Construction - GW1_20240528

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
( ts.14`.WATERZONES'd1 d ' •
Well Contractor Name SJ y�W" FROM TO DESCRIPTION
11‘ta... 4 , .„.-c....,.i..,..,.-, ., ,,,,c.----. ,-
NC Well Contractor Certification Number MAY�� 4i S 2024 16,Zft S ftkou, +n �A�
Y' 15°OUTER✓CASING•(foimnrti=cased"we1LiV)/;oRR'TTNER(ifa ci1i1e):.
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL
'.r... ft. ft. in.
Company Name
f 16 TNNER'CASING:OR,111BING_aidthermaldased=lghTi))'
2.Well Construction Permit#: itU.y FROM TO • DIAMETER TRICKN SS MATERIAL
List all applicable well construction permits(Le.(IIC,County,Stale, Variance,etc) .Y 1 ft. i 0 ft. C• ( ')Tin 6.J,2, �'VC
3.Well Use(check well use): ft. V ft. l ` / in. V 1/` v
Water Supply Well: FROM i TO DIAMETER—_SLOT SI THICKNESS MAT
['Agricultural ❑Municipal/Public /ft
`
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft (/ ft 7
❑IndustriallCommercial ❑,Residential Water Supply(shared) 1,'18"GROU'1'
❑Itrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 2 1 ft. a Chi. s- ('/'P..►/7 / 1,2.6di f
DMonitoring [Recovery ft ft. r
Injection Well:
ft. it
❑Aquifer Recharge .❑Groundwater Remediation
i`.19.SAND7GRAVELEACK'(ifspplicibleyi _ - - . .
['Aquifer Storage and Recovery ['Salinity Barrier FROM TO MATERIAL/ EMPLACE METHOD '
❑Aquifer Test ❑StomlwaterDrainage ft. ft
['Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer ':20.DRIr .fNGLOG(attach idi ithmal'sheeth if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,saillrock type ga n size etc)
Date Well Started 1�f 1 �14 a. D ft, f ft, � '._',/
/
4.Date Well(s)Completed: 17_Q Well ID# "yACc.J 7 f ft. G ftL�dor ,A___ (���
5a.Well Location: Phone#:,p3 34,-7 5-Z-d 3y%Z Mft Q6j7✓7 ft I i�hck_,OC� lofty Pigott
����J�l If���l�I il y%/7 /'{ l CAI/ �"ti a V-( /4f,f 677 ft.g✓VOJ ft'
�i�.nit- I'D C t- N1 CI�SG�9"'
Facility/Owner Name -�+ C Facility�1DD#(if applicable) (I 3' /e r1„ ft J7
i10 6 1 { ft. 1/ ft.
F es Are
cxu�
(n /At eyiAli
Physical Address,City,and Zip in;t;\HC•f y 1 Oc y® ft. ft.
t '.:21`S2E.MARKR . . .
k,:ejeti-e 5- Neks WI
Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field,one 1at/long is sufficient) 22.Certification:
z6, ‘rs 1 N ii, _1 413 W LT-17-2.Y
6.Is(are)the well(s): jrermanent or ❑Temporary Signature o Certified Well Con ctor Date
r By signing this form,I hereby certify Met the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or o 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 explain the nature of the of this record has been provided to the cell owner.
repair tinder#21 remarks section or an the back of this form.
23.Site diagram or additional wall 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 GWrl is needed, Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) Submit this GW-1 within 30 da)s of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2©100)
24a. For All Wells: Original farm to Division of Water Resources (DWR),
10.Static water level below top of casing: ✓V 0 (ft•) Information Processing Unit,1.61'1 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
// 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Boreholediameter: (in.)Bit Off:p�QG/7 Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 61,(' I/ Y o ra?'<y 24e,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
" � e Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) r Method of test: (1
70% hth oz Date Site Visited: f (, 2
13b.Disinfection type: Amount: 1 Q Site Visited By: I< iit 0 2 r»t
N--"-
post OW-1 � ., 'na Department of Environmental Quality-Division of Water Resources Revised 6--2D18