GW1--04308_Well Construction - GW1_20240722

u CWELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
4.
1.Well Contractor Information:
J 00�[411 Y1 el I•? C.1.4.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
71 G s ft ts r ' Ir., Ss r9ha ^
NC Well Contractor Certification Number �Pe ft /e?, tt, / rM sot''a4'pi l
15.OUTER CASING(toi malti-case [reps)OR LINER.(Nip lieabie).
Yadkin Well Company, Inc. FROM TO DIAMETER ,THICKNESS 1 MATERIAL
ft. ft in.
Company Name 3 , ^
/ 16.INNER CASING OR TUBING(geothermal dosibd.loop)' .J
2.Well Construction Permit#: I �p FROM TO DIAMETER _THICKNESS _ MATERIAL
List all applicable well construction permits(i.e,UIC,County,State,Variance,etc.) l ft. 51 ft .i.Sr r Mei t�'/Dg.�j f VL
3.Well Use(check well use): ft. V ` it In.
Water Supply Well: FROM o DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft ft in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O'ft 24/ ft /3 eh fpv(G/ _
❑Monitoring ❑Recovery ft. ft.
Injection Well: -
ft ft
❑Aquifer Recharge .❑Groundwater Remediation _
i 19.SAND/GRAVEL PACK(if applicable)
oAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRIMIIGLOG(attach additional sheets ifnecessity)
❑Geothermal(Heating/Coolin Return ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soilirock type grain size etc.)
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Date Well Started 6,-/i-d ��jj D ft c0 ' ft SD i7
4.Date Well(s)Completed: her•/ )41 Well 1D#,_A-4/pp'-'4R gd ft- 9e..7i n' nJ:/,.r4 A,/276,300vv/J
Phone#: 12 4_-)(p -1�'Ee u G'ron, it
5a.Well Location: ft. ft �`re7
GAF/ e.tty CV ft ft f,s -.
Facility/Owner Name Facility ID#(if applicable) ft ft +`�. ,. •�� •t 1
� � ,'�� ,:c� -Se�.r�o.,AG ft JUL 2 2 2024 TT"L
Physical Address,City,and Zip '1$�5 ft ft
�/ OG :.2L'REnfARxs�:' lair-3+rr+ ri Pry'�sns�g URN w/.
County a !/e' Parcel Identification No.(PIN)
3� �^'�''
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one 1at/long is sufficient) 22.Certification:
36 ,-) /Lr N Zr, I (II 3o ( W r
6.Is(are)the well(s): ermanent or OTemporary Si? ofC •' Well C at} Date
By signing this form,I hereby certryy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 0 114 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 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.
drill : L/ • 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ??-3 (ft.) 9.3
Submit this GW-1 within 30 different days of well completion per the following:
For multiple wells list all depths if erent(example-3@200'and 2®100) �`
s 24a. For All Wells: Original form to Division of Water Resources (DWR), 9....)10.Static water level below top of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: 6. (in.)glt Off: . d�5
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
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Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Vietlf Y1 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
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 90 Method of test: �,,Yc:§
u Date Site Visited: / -2 --.2. ?
13b.Disinfection type: 7O�o hth Amount: /.a OZ Site Visited By: L
Form GW-1 _ North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018