GW1--03573_Well Construction - GW1_20240613

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
rS er(y Wq�Ict-•$ C.'.14.WATER ZONES . . '.
Well Contractor Name
- 1 FROM TO DESCRIPTION
' ft. t 3e ft. 4 GPm 3 149 30C.T
3 NC Well Contractor Certification Number ft a t S ft G QrYi
15.'OUTER CASING(for multi=cased wells)OR LINER(if tip licable)
R
Yadkin Well Company, Inc. FROM TO DIAMETER TCKNFSS 1 MATERIAL
ft. ft. in.
Company Name (� '16.INNER CASING:OR TUBING/y�.eothermal closed-loop) '��
2.Well Construction Permit#: 390 9-CA FROM TO DIAM TER THICKNESS _ MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 1 I ft. /02 ft. &9 4 in. srf.3 I INC
3.Well Use(check well use): T ft. ft. in.
Water Supply Well: `17 SCREEN.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. In. .� "
❑Geothermal(Heating/Cooling Supply) iesidential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18:GROUT
❑hrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0ft. q ft' f1014 f'OCi &re J S lit
�
❑Monitoring ❑Recovery ft. ft. , n
�` au".(a6pr�11 1"VM�d
Injection Well:
ft. ft. •ir-0
❑Aquifer Recharge •❑Groundwater Remed ation ; 19.SAND/GRAVEL PACK(if applicably
DAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD _
❑Aquifer Test ❑Stormwater Drainage ft ft.
❑Experimental Technology ❑Subsidence Control ft. ft if-
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) FROM TO DESCRIPTI:OM(color,hardness,soli/rock type,gain size etc.)
Date Well Started SI31 I3y � 0G0 50,
4.Date Well(s) b'I Completed: $ ► Well ID# n /j l/ 60 ft ft 90 ,Sq 4 pnr
5a.Well Location: Phone#:� "
3�5(�- 77l-`Li 30 90 ft.
2(9 2 ft G�,ci��l,�
t /" Arc W jdz 11 ft. ft.
Li LN/ 4- Ape" I Eat' Kit 5,, sett r
Facility/Owner NLme Facility ID#(if applicable) ft. ft •W ` `e r a
/.tila Wc l r",Pitied 2Fc6t3 ft. ft j t i
1 ft. ft �)^ 2024
PI sical Address,City,and ZipI
� 21:REMARKS
II',i`Firtr,&sg,1 1n`,,^904^.1 UP.i:
County Parcel Identification No.(PIN) ow Cif ICA;
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
•
3 " 1/6//3 N k/.. S g'.SLr W tAJ _ SI3tl, y
6.Is(are)the well(s): ji'ermanent or G r rnporary Signa a of rtified Well Contractor Date �i
.1 By signing this force,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or YL, o ISA 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 web 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 I GW-1 i�needed. Indicate TOTAL NUMBER of wells
drilled: , (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: es,(OD (ft.)
For multiple wells list all depths ifd;i Brent(example-3Q200'and 2Q100� 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: so (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: 6 (in.)Bjt Off: L .d i 1 24b.For Injection Wells:Copy to DWR,Underground Injection Control(1UC)
Program,1636 MSC,Raleigh,NC 27699-1636 .
12.Well construction method: G t r l0 / 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 CJA
y Permit Program,1611 MSC,Raleigh,NC 27699-1611 ��
13a.Yield(gpm) �Q Method of test: i^/6 Af/
70% hth Date Site Visited: t!-2 3 .2 3 /N l4-' 2.H -'�
13b.Disinfection type: Amount: JO OZ Site Visited By: -,44
r
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
Price: