GW1--03249_Well Construction - GW1_20240528

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: /v� a)
\ O�Y W J I �I G-� 1 '�I 1 s 3.....,tb
74.WA zol�s : -Th^
Well Contractor Name PROM TO DESCRIPTION V,
k566-� y ft. 1fc ft. It r� ft
NC Well Contractor Certification Number ":U f L 0S �� +�
15:OUTER CASING(for mnl wells,)OR LINER(if:ip licibTh) O
Yadkin Well Company, Inc. PROM To DIAMETER THICKNESS MATERIAL
Company Name 33G.- y4 )-F32S + 1 ft. 24 ft. V 12S in. SDR-21 f VL 0
,Sy re y ';16:INNER CASIIV G:OR:ToBING.(gtodiermal cloied4i oP)
2.Well Conty action Permit#: ( k W L 202 3 63.T . FROM TO DIA ER THIC KNFSS MATERIAL _
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) ft. ft. in.
3.Well Use(check well use): it ft in.
160
Water Supply Well: i17....S�
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
['Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) (1 eesidential Water Supply(single) ft. ' ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) :ig GRour
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 2 Z ft 1 s fL ` L
131,
OMonitoring DRecovery S. ft � r p) �� `�
Injection Well: ft. ft.
-
❑Aquifer Recharge ❑Groundwater Remediation
i 19.SAND/GRAVEU PACK(if apPlirhble)
DAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test DStormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) DTracer 20.DRIZI•:ii GLOG(attach additional sheets if neces ai ) ' - _.
❑Geothermal(Heating/Cooling Return) ['Other(explain under#21 Remarks) FROM l TO l DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
Date Well Started O S •06=2A 0 ftg ft c,ic/
4.Date Well(s)Completed:
( S47 24 WeUID# AA -017 9 ft. 70 ft L.a4st Dif`f' MAY +I S 2024
Sa Well Location: Phone#:$T.3•'93Y,7 M 71 ft. 9 4 ft 9 NIA/, Q
oskut a C e r I S so. 8 5 ft 144 6 ft Pdv i.n s d f .r,,►A M.- IFacility/Owner Name Facility ID#(if applicable) f K' ft' 6 00 ft. •A 1-10-C. h d 44 t s C f- .w e
tint 3e-�u G.voue CiN,RA pJ/it 111/.. ff. ft.
ys MC.1 ft ft
Physical Ar'.ireslss,.City,and 'p
SW i /t 21 REMARKS
County Y (PIN) ��e.ft/.5 p.�wP ne6.P a d 3 tlo.-. far 51100454..
Parcel Identification No. 5*5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: tot St
IF-
(if well field,one lat/lonng is sufficient) 22. • tification:
3C .,
6. / /2 .5- N ECf . TLO L g 77 w rid/4;4_
6.Is(are)the well(s): lrmanent or ❑Temporary Si of C-.��ed well ContractorDate
,�,�f By signing t ,.form,I hereby cernfy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or �d 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 Q..
construction,only 1 GjtV-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: ! i
L/� 24.SUBMITTAL INSTRUCTIONS
U 9.Total well depth below land surface: p (ft.) Submit this GW-1 within 30 days of well completion per the following: SU
For multiple wells list all depths if different(example-3@200'and 2Q100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: V (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level it above casing,use"+"
24b.For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
11.Borehole diameter: (in.)Bit Off: (j.b4 0 Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 4i✓ Ito IA a-y 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
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: ,( r
70% hth �J Date Site Visited: /-J-- 2- S�
13b.Disinfection type: Amount: v"7 OZ Site Visited By: 15'1'g
Form GW-1 u^'''"-nlina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018