GW1--03589_Well Construction - GW1_20240613

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
0
1.Well Coatr for Information: S
hii P1 L Ca { i 4:WATER.ZONES
WellFROM TO DESCRIPTION d
Contractor Name
3s Lt A) ft. ft
ft. ft
NC Well Contractor Certification Number :15.OUTER CASING(fit multi-cased wells)OR LINER(if rip licable) . '
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL" Q
ft. ft. in. CZ.
Company Name
3 r 1/ L/�� ''16:INNER CASING OR TUBING.(geothermal closedloop)
Z.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable arll construction permits(.e.UIC,County,State,Variance,etc.) ..{.I ft. 1!?ft. (t �2,�• (t QR'4 n vC-
3.Well Use(check well use): ft. ft. in. ✓ r
17.SCRE 1.
Water Supply Well:
•
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural `❑Municipal/Public ft. ft in.
❑Geothermal(Heating/Cooling Supply) SResidential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) :18.GROUT
_❑lrrigation ❑Wells>100,000GPD FROM TO MATERIAL L( EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft S ft '�{/lle^r li �iP t} Fi,�
❑Monitoring DRecovery ft. ft
Injection Well: ft. it �QJ 3
❑Aquifer Recharge • .❑Groundwater Remediation ,
i 19..SAND/GRAVEL PACK Of applicable)
❑AQuLfer Storage and Recovery ❑S Salinity �
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft
DExperimental Technology 0 Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets If necessary) :':.t ;.
❑Geothemal(Heating/Co lin ) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain sbre,eta) F.
Date Well Started a D ft- qa S' •► C
4.Date Well(s)Completed: 'S"a Well INAAf M 7OO q,Z ft• T) ') ft si a fu7 #dr4/if
Phone#: 433- Li77-do. 3 !
it-
Sa Well Location: 3 co�U ft. /� ft M f• 5/a7 a.,i'D et/g1.-
Roy M.11 a a a sdn ft. ft ;- ._ _.+ ✓
cfr • 00
Fac /Owner Name Facility 1D#(if applicable) ft ``�`'` (n
T &) ?..1.c. Sri/Lclt p1 S oosc,, .?.me . O1 ft. f. JUN 1 : 2024
Physical Address,City,and Zip ft. ft
h.(G,sti4sw.t,t
kAi �t>C iJ- � 21.RF.MARKR �.. ` f}(� .+�i.$''1
County Aistath
A 3 Parcel Identification No.(PIN) �O�rc 1\t� ���QO ��V--� v OV e V
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �'`�AA0`— SQ 0 p s
(if well field,one 1at/long is sufficient) 22.Certification: �®V t -Soo P S i
It
l ti
wSignature of Certified Well Contractor Date
6.Is(are)the well(s): Xermanent or ❑Temporary
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or )(No 15A NCAC 02C.0100 or ISA 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 to provide additional well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: I 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: I Q , ( ) 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)
10.Static water level below top of casing: X° 24a. For All Wells: Original form to Division of Water Resources (DWR),
(ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 1 j)
If water level is above casing,use"+"/
11.Borehole diameter: 6 (m.)Bit Off: P , G( r 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: a;/ ere e7L4 p y 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
13a.Yield(gpm) ' Permit Program,1611 MSC,Raleigh,NC 27699-1611
Method oftest: / A/!
Date Site Visited: /9- .2 3 1<
13b.Disinfection type: TO o�o hth Amount: OZ Site Visited By: A4 -tt
3. , , g tit
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
Price: S-c.e.. (an 'r wc.../-