GW1--03277_Well Construction - GW1_20240528

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: Iv
V CI_ i- 'li 1 S 04:WATE22'ZONES i fti • �0
Well Contractor Name FROM�• t TO DESCRIPTION ,(�,/'���, �/�
C 1 .4 � 7(it- / ' ft. P P--. 3 C+l v r�rl'+ 7 C k
J �® ft. • ® ft
NC Well Contractor Certification Number :15.`O VTERCASING(foi'mrild-METEweIIsjOR'IINERAifap'llcalil'e)'::., .
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL (P
ft. ft. in.
Company Name
L s y 'S6-NNER:GASING:OR;1 i It NG((gaothecmil do'ied=loop) . _ .
2.Well Construction Permit#: V 9 � FROM TO . DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Cotmty,State, Variance,etc) * I ft. 1 2'9 ft �,,2 i&L t IFS'
(e'7-CA
3.Well Use(check well use): ft. ft in 'u ,
Water Supply Well: -t:17 8-.0 , . ,.,., • • I
P ft. ft _.. SIZE:_.. H :...._. .
FROM TO DIAMETER SLOT THICKNESS ."MATERIAL
❑Agricultural ❑Munici aliPublic -
❑Geothermal(Heating/Cooling Supply) XElesidential Water Supply(single) ft ft in.❑Industrial/Commercial ❑Residential Water Supply(shared) '18 GROUT t 1"
❑Irrigation ❑Wells>100,000 GPD FROM TO TERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: (� "
❑Monitoring ❑Recov /
Injection Well: �Y (� ft. . ft 6t9�f'r'i�Yl �jel.-tpC`�f
ft. ft / i
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salmty i Barrier 1'19.SAND/GRAVEDT.A.CKy('f-aPPliable)`, V,�,
FROM TO MATERIAL EMPLACEMENT METHOD �M
DAquifer Test ❑Stormwater Drainage ft. ft Ib
❑Experimental Technology ❑Subsidence Control ft. ft. 4
❑Geothermal(Closed Loop) ❑Tracer ,20.DRILLINGI,OG(attachaddltionnIsheetiifuecneary)
❑Geothermal(Heating/Cooling Return) [1 Other(explain under#21 R:.marks) FROM TO DEscRIP:TON(r lox,hardness,satUroetc type,grain size,etc.)
Date Well Started �'-/Z,00' ^qq�y () ft /Pyft 34,: 1
4.Date Well(s)Completed: Z-%7., _Cr.-YWell m#AA(lt Ian icy/ft q®o+it i/ 504#
I f
5a.Well Location:: Phone#:336— 774g71 ft. ft (], /, f t i V'Y'OV l a
Jof to h l o 4 f `( ft. ft. „e..-
/O
Facility/OwnerName Facility ID#(if applicable) �y ft. it. '^
C-5-113 f r 1�y /�'�!� 1-is 1 W'T 4-tiC01F 0t9d' ft. ft !Mill'.' G :;07i
Physical Address,City,and Zip ft. ft.
County Parcel Identification No.(PIN) 1 ac7 W z•T /i® 95 O " 'to C
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: j4' -� .y ilo®
(if well field,one!at/long is sufficient) 22.Certification: "6.Is(are)the well(s): j}kermanent or ❑Temporary Sr e of C d Well Contractor Date
z
By signing this farm,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or ,Vo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
40.
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.
repair under#21 remarks section or on the back of this form. 1
23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GT-i is needed. Indicate TOTAL NUMBER.of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.3
drilled:
/ 24.SUBMITTAL INSTRUC l IONS_ Q
9.Total well depth below land surface: etf 00 (ft.)
For multiple wells list all depths if different(example-3@200'and 2(4100� Submit this GW-1 within 30 days of well completion per the fallowing:
10.Static water level below top of casing: 6' _(ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If Ovate level is above casing,use•+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 •
11.Borehole diameter: 4 (in,)Bjt Off: (moo -i 95 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC) ®o
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: f1 t / w/ 24c.For Water Supply and Open-Loop Geothermal Return Wells:Co to the N(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed Py 'T
FOR WATER SUPPLY WELIA Vris,�%/�rule,, 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
i f Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: f/9 id i f
70% hth Date Site Visited:
13b.Disinfection type: Amount: °'? OZ Site Visited By:
-Fre-c P.E.i 1-'''''II
ru
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources 'y� Revised 6-6-2018
Price: 'y h nl,.