GW1--04318_Well Construction - GW1_20240722

TRTJ�C For Internal Use Only:
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1.Well Contractor Information:
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�J ri4-K — FROM TO - I DESCRIPTION
Well Contractor Name Wft- 24- 6 ft- fyctj:�, , Vkh
ft. ft.
FROM TO S MATERIAL
Yadkin Well Company, Inc. ft I IAMETER I THICKKES
ft. I in.
company Nameovprla� 4qlcr- **2- 3�rzc>
FROM To DLa1CtTER I TMCFtIum MI TXIIIAL MIAL
2.Wall Construction Permit#: ft- 11*3 f' I&b in- 1-16% 194m,
List all applicable well construction permits rx.e.EUC.COUntY,Store,Variance,eta) 41
3.Well Use(check well use): ft ft- In.
Water Supply Wen: FROM TO DUbIUM SLOT SUM THICKNESS MATERIAL r
OAgricultural [IMunicipalftblic, ft. ft in
oGeoth—al(Heating/Cooling Supply) hfesideati.1 Water Supply ft. ft.
01ndustrial/Commercial DResidential Water Supply(shared) f.
01nigation OWells>100,000 GPD FROM TO MATERLU, F2,EnACEMMV METHOD&AMOUNT
Non-Water Supply Well ft. il f, cqr&w+r ou&qs
DMonitoring oRecovery ft. ft
Injection Well: ft. ft.
DAquifer Recharge oGroundwater Remediation f 19.
ElAquifer Storage and Recovery oSaliaity Barrier FROM TO I MATERIAL MYRITACKMIM METHOD LA
E]Aqtiifer Test OStormwater-Drainage ft• ft.
oExperimental Technology OSubsidence Control ft. ft.
DGeothermal(Closed Loop) OTracer ":20:DRIftI1VGTOG(iitticiiiadwi5&11hiiti tnne6ni : tA
FROM TO DESCRIPTION(color,hm-duess,soll/rock type, size,eta et )
EiGeothermal(Heating/Cooling 00ther(explain under#21 Remarks) ,
Date Well Started. &-&-2M 0 fl- 12. ft.
4.Date Well(s)Completed: If-121--m welln)#AAQ-�'ol- A;, fL 140L ft- 44+ wfp*
5s.Well Location: Phone#: c?I q- -3J-7-QPIK Ill. 't• io-al ft- Ary 14 tT?_y1qWWK (71
1­10%ca Gvce^ R-0 Ll Wj ft. I cyX f- tW� OW cha�ky K
Facility/owner Name 0-dj-m Nr". FacilityM#(if applicable) ft. ft.
ft fL
30!t7 C_aeraj Girrvtk RA M//JAu-*-*LJ14 _
Physical Address,City,and Zip Nic airls/ ft. ft.
t!f-,ffl!n4-A-
County Parcel Identification No.(PI) JUL 2 G 2024 Cl
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 6h4
(if well field,one lat/long is sufficient) 22.Certification: D1,r.;31t CA;
ea( N
Signature of Certified Well Contractor Date
6.1s(are)the well(s): @Kermanent or OTemporary (13
By signing thisform.1hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: oYes or M<o 15A NCAC 02C.0100 or 15.4 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.
rep
air 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 bark of this page to provide additional well construction info
construction,only I GW-1 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
9.Total well depth below land surface: 00 V (ft) Submit this GW-1 within. 30 days of well completion per the following:.
For multiple wells list all depths if different(example-3@200'an1 2@100D
Iy Ma. For All Wells: Original form to Division of Water Resources (DWR.),
10.Static water level below top of casing: 70 (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
24b.For Injection Wells:Copy to DWI;,Underground Injection Control(lUC)
11.Borehole diameter: C- —(!-.)Bit Off:5-610 Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Ar"' IL40--Se 24c.For Water$apply and Open-Loop Geothermal Return Wells Copy to the
rotary,(Le.auger rotary,cable,direct push,etc.) county environmental beat th department of the county where inio_j
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000
" ..GP Copy to DWR,CCPCUA
13a.Yield(gpm.) Method of test: Permit Program,1611 MSC,Raleigh,NC T7_699-�6_1 Aw kA.
I Date Site Visited: 4-'�-2- mi Z
13b.Disinfection type: 70% hth Amount: Oz Site Visited By: 6%M
t
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018 t.,f
Price:- F V