GW1--03262_Well Construction - GW1_20240528

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
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1.Well Contractor Information: {rV Ci (,V 1' I ►,�./ (4 t I- 10e- •:1J 4:WATT'ZONES ;r: • 4
Contractor Na �
/� FROM TO DESCRIPTION
Well Con
ti 5 ft. ft
ft ft
NC Well Contractor Certification Number t.1 OUL5Bt':C4.SIN(. (formuJticased'wells):ORLTNER`(fap"licatile).: 11)
Yadkin Well Company, Inc. FROM TO ,DIAMETER THICKNESS MATERIAL -I
ft. ft. in.
Company Name ^
I N 165INNERCASING.OR7'lllilNG(ge`o. ....iikl eldtea=l6oi'
2.Well Construction Permit#: FROM TO . DIAMETER THICKNESS MATERIAL. ..
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. ft in.
3.Well Use(check well use): ft. l ft in n
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) '18';GROUTz':_.',
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation -.
❑A uifer Storage and ❑Salim Barrier I`D.SAND/GRAYEI:PACKjCsf5pplicalile) .
Q Recovery ty FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20:DIt fl NGLOG(attach adthtaonaliheetj if necessary) ••.'::::;i, : :
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil rock type,grain size,etc.)
Date Well Started 0u-7.-9-Di 0 ft. •z 15 ft. es tail. j 1{
4.Date Well(s)Completed:O'4'30-21 Well ID ilia- 17 3 3(.6 ft 3 2.0 ft se.+kta( J fe J;,- ..
5ra.Well L�oc/ation: /� Phone#:74S# �- 902-� z z3/ oft. y 4 Oft fie,.j.1 c ,f ) GCdNt,/f r6
l• `�I� Vt�11��J PVeG4 it SI.4)44 Or ft. ft. -�
Facility/Owner Name / Facility ID#(if applicable) ft. ft.
-_APT A V • 424
.U( Qom( a A- n L4,. . ,gc ft ft.
Physical Address,City,and Zip J�r,( ft, ft •2 'N
`e`v_ ` r
. ?...,
Tr e A e I / /_ '_�,,,- I -. .�sl+,.. . .... w
County (` Parcel Identification No.(PIN) G l C'w"e Q L _�1 .__al a.+ 41
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: d r 1•'l 4 d -dee
(if well field,one lat/long is sufficient) 2 C tificatio
it-
3 , o32-7'1 N Aso: 9'2c4i- 9 w i`l ,Gc , 4 .30 -2LI
6.Is(are)the well(s): lJrmanent or ❑Temporary ri( I afore o edified Well Contractor Datertm
/ C(GAL A'7 "i l By sign' this form,I hereby certify that thew (s)was(were)constructed in accordance with
7.1s this a repair to an existing well: [)'Yes or niNo deyo V 15A NCAC 02C.0100 or 15A 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 remarla 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.
drilled: 24.SUBMITTAL INSTRUCTIONS LP
9.Total well depth below land surface: Lt -1 O (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) 1
t,� 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: -L (ft.) formation Processing Unit,1617 MSC,Raleigh,NC 27699-1617 V"
If water level is above casing,use"+•'
1 "
11.Borehole diameter: (in,)Blt C S. 9 2 S 24b.For Injection Wells: Copy to DWR,Underground Injection Control(TUC)
//;; Program,1636 MSC,Raleigh,NC 27699-1636
t/�12.Well construction method: I r ,f 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
13a.Yield(gpm) sd Program,1611 MSC,Raleigh,NC 27699-1611
Method of test:
o Date Site Visited:
13b.Disinfection type: 70�O hth Amount: OZ Site Visited By:
Form GW-1 North Carolina Department of Enviroruuental Quality-Division of Water Resources Revised 6-6-2018
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