GW1--03264_Well Construction - GW1_20240528

-WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
I •/4 t /LG1, rg()W►1 14.WATER ZONES
Wall Contractor Name
FROM TO DESCRIPTION
ft. ft.
3 0 3 6 A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Yadkin Well Company, Inc. FROM ft TO /fL DIAMET in.
_
THICKNESS . 1 MATERIAL
Company Name ,/j
�'a _w� N G` � 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit II: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. ,os s ft. /D in. 5,.1 v ` 6.1V,.j-- a eii t
3.Well Use(check well use): ft. ft. V in. h 7ll r r
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. I
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in. /V
❑Industrial/Commercial DResidential Water Supply(shared) .....2„.....„..---
18.GROUT /
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ® ft. ft. /Y liu C/ 4.. e.,Mpl N/ s` ifer
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(If applicable)
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. t't
❑Experimental Technology ❑Subsidence Control fI /-' /
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional heets if
( necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM I TO DESCRIPTION(color,hardness,soil/roek type,grain size etc.)
Date Well Started yff5/xAii A ft. u- tt -�%, C1Ay t ivaf,el4.Date Well(s)Completed Well IAA".qqg /j f_ft' o� ft. .4 44 G��,'�G
5a.Well Location: Phone#: •'J QV ..J _ 4r� ft, 70 L ft- /( el / [aid (y/a 1
ft. fL /
cA of.4 Fa vA't,i-
Facility/Owner Name Facility[D#(if applicable)
Wft. ft.
y l TO SCii4irri tY - i @t
Physical Address,City,and Zip ft. ft. 4, it -/n r I
V ZI a 21.REMARKS ` �/ 'a-_-_�
County ~ Parcel Identification No.(PIN) B es th.( n DN,.,f1 -0 '7 r i.,fw 'game
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: e " &_i/
(if well field,one lat/long is sufficient) 22.Certification: SDR of Loops
i 21' . 194 N `11. FloS'7 54� w \...._____._ - 7.,,)-C?'6?-1
6.Is(are)the well(s): OPermanent or ❑Temporary igrtature of Certified Well Contractor Date _ 1
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or dNo 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.
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.
drilled: 24.SUBMITTAL INSTRUCTIONS
�]
9.Total well depth below land surface: r/oX (ft.)
For multiple wells list all depths if different(example-3 a@200'and 2@1000 Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
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"+„
11.Borehole diameter: '""""
3
(in.) r"^ 46 18 M 24b.For Injection Wells:Copy to DWR, Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: G r folain7 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)_ 1 CI
A-IMethod of test: + J
13b.Disinfection type: 70% hth Amount: 5 3 OZ
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
Price: