GW1--03269_Well Construction - GW1_20240528

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: 3
1.Well Contractor formation: /�/) ` t
Coil/ d#1-6 Is R�"yJ f JQrt 14.WATER ZONES
Well Contractor Name FROM TO I DESCRIPTION C ��,� / �j
/ f J 04 ft. to i ft ti,.t 1 fa 1 Q TM- 1,C�. l•,1-/T
��\ fs J ft. l ft. se
ft
Well Contractor Certification Number 15:OU11':R CASING(for multi=cased wells)OR LINER(if a2plicable)
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNF_SS MATERIAL
ft. ft. in.
Company Name S y('• 2..41- 2-1 1 IS
�� ��.}_.,. 16.I NER CASING OR i'L1BING:(geotheimal dosed=loop)
2.Well Construction Permit#: s - FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ,. I ft. /_ u ft j Y1 Q in. 6D.`3` 11 c.
3.Well Use(check well use): Zi -
! ft. W '1 ft. V "1 in. K 1 rJf
Water Supply Well: 1.1'SCR '
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
b4,gricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) 0Wesidential Water Supply(single) ft ft. in.
❑IndustriaUCommercial ❑Residential Water Supply(shared) 18.GROUT°'
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: �0 ft. R^ ft , ,,IN c..k A_..,i 1,1y tl. a
lgt
❑Monitoring ❑Recovery .J ft. �1(� ft. �f 4J �V
Injection Well:
ft. ft.
DAquifer Recharge ❑Groundwater Remediation
i 19.SAND/GRAVEL PACK(if applicable)';..
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
[Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer ' 20.DRILLINGLOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soillrock type,grin size,etc.) _
❑Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) ‘
Date Well Started i.1 D ft. 43 ft. ) I
4.Date Well(s)Completed: lr II".2 Lt Well ID# 4 A 1 6til ft. pa ft f'A'L.3 r'?I 1-t4iN aT r 50 p
Phone#: 76 • 937-97S.ty ea ft. 333ft ohtsn.y I rn`te 004 64,6)
Sa.Well Location:A4.4
� 1 i r1 L�.r1� [����/
Ca Ail a 4 1 t h 43 z ft. 8-0/% ft. LY 17\ �-- c
Facility/Ov/S er Name ,y ) FacilityL1D#(if applicable) ® J ft. ,J ft.
27 S F- �f i.t-1 L e,r ","T.�) N C 16 ft. ft.
Physical Address,City,and Zip ✓ ft. ft.
21.REMARKS
a21tfi Jvr. .
County Parcel Identification No.(PIN) +4 t
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: t�
(dwell field,one lat/long is sufficient) 22.Certification: I t�AY :+ S 2024
w (-7-/- 167"-------
rt
6.Is(are)the well(s): ermanent or ❑Temporary Signature edified Well actor Date 4'
_� By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
1Vo 6
7.Is this a repair to an existing well: ❑Yes or C7 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 xn 11 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
g)
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).Ycu may also attach additional pages if necessary.
drilled: / 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: TO (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3(200'and 2@100')
f c> (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR), (( "
10.Static water level below top of casing: Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617 011
If water level is above casing,use"+" 1
/ r 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.)BIt Off: ` Program,1636 MSC,Raleigh,NC 27699-1636 1
12.Well construction method: 44, 47-A-414gerf24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the .i-'
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
S
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA raw
i'/ Permit Program,1611 MSC,Raleigh,NC 2769 9-1 6 1 1
13a.Yield(gpm) I a Method of test: rt JJ
o Date Site Visited: 4-//- 2 3
13b.Disinfection type: 70 o hth Amount: 3y OZ Site Visited By: »9
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018