GW1--03576_Well Construction - GW1_20240613

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
_5.ecc- (di a4-ks rS �_.14:WATERZONE$ .c�
FROM TO DESCRIPTION
Well Contractor Name �.
a Li.Ss - A ft. 6 1ft 3 6�,,,
ft. /ID ft. 3 661,1
NC Well Contractor Certification Number 15.'OUTER CASING(fdi malti-cased wel LOR LINER(if sip licible)
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL 0
ft. ft in. D
Company Name
) ` v1 ''16:INNER CASING OR rUBING:�eotermal closed-loop)
2.Well Construction Permit#: /] V FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) T i ft. /_C/ ft. G yy in. ERR ' Pi G
3.Well Use(check well use): ft. V f ft in. Y
Water Supply Well: 17.SCREE) , _
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft ft tn.
❑Industrial/Commercial ❑Residential Water Supply(shared) : is.GROUT _
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: v ft. o)y ft l4ole f 105 PO urea iO S
❑Monitoring ❑Recovery ft. 7 ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.$AND/GRAVEL PACK(if applicabkl
[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.DRIC.CSNGLOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Re�) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,so;Uroetc type,grain:size,eta)
Date Well Started +13 I I ry O ft' ft son
4.Date Well(s)Completed: L 1317 j Wen mm#AAd- ®-�t 3S ft- 323. ft G f�t.f1S Vr
Phone#: -III" (S- `7. 91 rt. ft .4 -
5a.Well Location: "� �l I
ft. ft. I ♦``P l�l �f E LJ
J as o4 ./�11er JUN 1 3 20Z4
Facility/Owner Name Facility ID#(if applicable) ft. ft
SA 2 .S4C.1e, IOW f NC tiab pc4 ft. ft Ir ;n7Lie?A Pretriaatv err,
Physical Address,City,and Zip ft. ft I Y:Qt.ELxs Z
/� /Q 1 21.RFMARKC
County ^L Parcel Identification No.(PIN) IF
5b.Latitude and Iongitude in degrees/minutes/seconds or decimal degrees: 6"
(if well field,one latllong is sufficient) 22.Certification:
30 j9 ' 3!" N O -iy 3(1 39' „ w
Wa`�i`� (. I3(sy ®tom
6.Is(are)the well(s):16ermanent or ❑Temporary Signature o Cert fled ell Contractor Date
By signing this form,I hereby cerffy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: [Wes orlo 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 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-xiprovide additional well construction info
construction,only 1 G7-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).Yet.may also attach additional pages if necessary.
drilled: 2� 24.SUBMITTAL INSTRUCTIONS
3 9.Total well depth below land surface: � (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if di ferent(example-3@200'and 2Q100')
30 (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
If water level is above casing,use"+"
11.Borehole diameter: 6 (in.)Bit Off: to .011 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC) ........
Program,1636 MSC,Raleigh,NC 2 7659-1636 6--
-_
12.Well construction method: tii,r r o G rJ 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 .4...
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) A Permit Program, 1611 MSC,Raleigh,NC 27699-1 6 1 1
Method of test:_ r• ('
70% hth Date Site Visited: j/ta2S
13b.Disinfection type: Amount: ILI OZ Site Visited By:_______________-
Form GW-1 /' North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
Prir-A' ri. CIA., Y//i--17"'