GW1--03252_Well Construction - GW1_20240528

' Wilt CONSTRUCTION RECORB (GW-i) For Internal Use Only: `"
3
t.Well Contractor Information:
Mali-'4l '.,:].4.WATER ZONES t _ �.w*' 0"- Brow• FROM TO DESCRIPTION �+� — �+ / r�'�'
Well Contractor Name ``1
® �'� 1 v 0 ft .2Z J ft..... fr�i 0 3,ro-3S"3 © 0- ps,
7 •
NC Well Contractor Certification Number 'It)fL 41 ft 070 liar-,� y�1 i o LID
15:OUTER CASING(for m'ultVcased wells)OR _LINER/ (if it 11=131e) '
Yadkin Well Company, Inc. FROM T DIAMETER THICKNESS MATERIAL
ft
Company Name ^'�— i
��a�� ap � �ieti .i16:INNER CASING:O1I IUBING.(g'ec:tlissrinal dosed-loop) ,
2.Well Construction Permit#:
FROM TO . DIAMETER TTHCKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County, e, Variance,etc.) t 2 ft. i I c*ft �'(.r/(y tn- G �u 6ely S.!- 1
3.Well Use(check well use): ft J ft ea O in Sih b / 7 C.0
) _ w/f✓FIVE �►Xt,..
Water Supply Well: 17.SCREED,
FROM T$/ DIAMETER SLOT SIZE THICKNESS MATERIAL
El Agricultural unicipal/Public f it in. �°'
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft ,/ ;^ s
❑Industrial/Commercial ❑Residential Water Supply(shared) 18:GROUT
CI Irrigation ❑Wells>100,000 GPD FROM _TO MATERIAL_ EMPLACEMENT METHOD 6,AMOUNT
Non-Water Supply Well: 0 ft. //d-ft �(// i t ^1 Aire / -s-,2 I• 4S
a
❑Monitoring ❑Recovery ft. ft T f �1
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation
i 19.SAND/GRAVEL PACK(if ipplieitltie'+.
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL f EMPLACEMENT METHOD '
❑Aquifer Test ❑Stormwater Drainage ft. ft. /
❑Experimental Technology ❑Subsidence Control t. ft
❑Geothermal(Closed Loop) ❑Tracer O.MIMING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soibrock type grain size etc.)
Date Well Started ii_ !7..„Ay 0 ft. 3 ft. .S--&
4.Date Well(s)Completed: / —23"'2'/Well ID#AP'(4 2- 3 ft. /0. ft /c.41ZA(r (/ &v . (` ,, f JsnsS l,�
Sa.Well Location: Phone#: Cii0 ' Zt ! T 37 /4„; ft. SiL ft. S(',��d. [
Lk ft. ft
S-+'o keS Grwurvr,y
Facility/Owner Namei / Facility ID#(if applicable) ft ft
• 4l Da b:AV ��/� _ ft. ft.
�� L �7�
Physical Address,City,and Loaf
51 ft. ft.
S- d kC—P 21 R RT{
EMAR
County Parcel Identification No.(PIN) •ld../ 6 I/ti 6/rt y
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: a�tAni it) it i/
(if well field,one lat/long is sufficient) 22.Certification.
36 `.2 , c (tic _N GOc► /G' e 92 W 9- 23 -2/
6.Is(are)the well(s): IPrmanent or ❑Temporary ignaturc of Cettifizil Well Contra`Ct r Date
+� By signing this forts,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 4�O 15A NCAC 02C.0100 or I5A 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 wed owner. it
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 needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary. T
drilled: / LL j 24.SUBMITTAL INSTRUCTIONS �LJ
9.Total well depth below land surface: �O L. (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Qa 200'and 2Q100)
t24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: t1 (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-I617
If water level is above casing,use"+" "e 7
"�'J 1 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: b (in.)Bit Off: Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Cl// r5s 7&/y CI
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 9)
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
.11(1 ,2.)'bt S�/''" a H C"`Permit Program,1611 MSC,Raleigh,NC 27699-1611 "
13a.Yield(gpm) Method of test:/' / f v"
o Date Site Visited:
13b.Disinfection type: 7O�o hth Amount: 6 OZ Site Visited By:
'Ig
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
Price: See st:Az.d