GW1--03285_Well Construction - GW1_20240528

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
-70
1.Well Contractor Information:
;c2�_(t kAkt3 :�14'WATE$ZONES
Well Contractor lame
FROM TO DES_ ION
�5'��-/9 3 7zft. 371-r ��.��� � r
ft. ft. 9 tO
NC Well Contractor Certification Number '15:'OUTER CASING(for`m•'niti=cllised Wells)OR LINER(if ipplicible)
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS I MATERIAL
ft ft. in.
Company Name
�j i�j •:16.INNER CASING ORTOBING. othermal closed-loop)
2.Well Construction Permit#: [ -[ £ 3 Q FROM TO DIAMETER THICKNESS MATERIAL�7 .�
List all applicable well construction permits(i.e.IWIC,County,State,Variance,etc.) /rt t (IC/ ft �� ' rin. C D j�_a 1 J i(
3.Well Use(check well use): ft ft in
Water Supply Well: i17.SCRE$(�. ;.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL' ^
❑Agricultural ❑Municipal/Public ft ft. in.
OGeothermal(Heating/Cooling Supply) residential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) :18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROMp TO MATERIAL EMPLACEMENT METHOD&AMOUNT
i1�
Non-Water Supply Well: ft el ft jQ,{�_dkias peuri f
❑Monitoring ❑Recovery ft ' ft ff//
�"S/Injection Well: �� _V l� .,,,„(9� -
ft. ft
❑Aquifer Recharge .❑Groundwater Remediation
i 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD f' _
DAquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology 0 Subsidence Control ft. ft.
❑Geothermal(Closed Loop) OTracer 20.DBXWNGLOG(attach additional sheets if necessary)
FROM TO I DESCRIPTION(color,hardness,soil/rock type,grain size,
❑Geothermal(Heating/Coolin Return ❑Other(explain under#21 Remarks) , etc.)
Date Well Started 0 ft �•] ft 5 d j
4.Date Well(s)Completed: y/�}• 9'f Well ID# �7'ft �+/o3' ft ed !o'{, te 1 Z rr 4e
77 G� G._ .
5a.Well Location: Phone#: - i„ jj''` ft. ft
2.Nit ,i)0/� ft. ft �- N... t `.,r, ri
Facility/OwnerN�e L �y ysFacilitylD#(ifapplicable) a.a' ft ft MAY Sj 2024
/‘3 f f*4 c1 , O /L�4h Art c&.1-C ft. ft.
Physical Address,City,and Zip _s�l lj i ft ft h, , ' -.-y.„1 •y _S.,.
- //Ljk ni N`�agii144 21.. t .
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
tk
(if well field,one lat/long is sufficient) 22.Certification:az it ',A' N,/,ii; r3-.2,d w 2 7
//
V1g"may, 00
6.Is(are)the well(s): �jPermanent or OTemporary Si o ed Well Contractor Date ;U
By signing this form,Thereby certify that the well()was(were)constructed in accordance with cts
7.Is this a repair to an existing well: ❑Yes orIo 1SA NCAC 02C.0100 or 1SA NCAC 02(7.0200 Well Construction Standards and that a copy 3
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.
CD
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details: C"'a
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 GW)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
i
9.Total well depth below land surface: 4d,3 ft
For multiple wells list all depths ifdi$erent(example-3Q100'and 2Q100� ( ) Submit this GW-1 within 30 days of well completion per the following:
s
10.Static water level below top of casing: iSO (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR), -"
If water level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in.)Bit Off: {f� 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IIJC) N
Program,1636 MSC,Raleigh,NC 27699-1636 \
12.Well construction method: Q
1(i.e,auger,rotary,cable,direct push etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
county environmental health department of the county where installed (1)
-ice
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) Method of test: 4/el
70% hth Date Site Visited: .2 7 -�3
13b.Disinfection type: Amount: -7•t. OZ Site Visited By: v F'
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018