GW1--04320_Well Construction - GW1_20240722

MT, ,CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Info f motion:
FROM TO DESCRIPTION
Well Contractor Name
ft. ? ft
ft ft
NC Well Contractor Certification Number 15:OIITER CASING fo'z'ai ficoded"wells"OR'ISNER(ifn ualile
Yadkin Well Company, Inc. FROM TO DIAMETER TffiCHNFSS MATERTAL
Company Name fi I ft. I l ft. in. k 1 v^ y. &
�j tc ) �j� �15 1NNMC-ASING_OR;TUBffiG if(thermal closed=lo6•` .. . .
2.Well Construction Permit#: T/T/.74.0 K�--Mfo"
To DL'TEC2 THICKNMS MATE IAL
List all applicable well construction permits(i.e.U1C,Cownty,State, Variance,sic) ft in. �•
3.Well Use(check well use): ftWater Su 1 Well:PP Y TO DIAM&TER SLOTSIZE THICKNESS MATKIRUAL
❑Agricultural ❑Municipal/Public ft in.
❑Geothermal(Heating/Cooling Supply) 0 esidential Water Supply(single) it in.
❑Industrial/Commercial esidential Water Supply(shared)❑Its ation ❑Wells>100,000 GPD To MATERI)d EMPLACEMENTM=01)&AMOUNT
Non--Water Supply Well: fr' 2 rt r (�
❑Monitoring ❑Recovery ft ft
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation
j'.19.SANI)IGRAVEIzP.AI'K`r 1i'ne `"
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERUL UN ENT'METHOD
❑Aquifer Test ❑StormwaterDrainage ft ft G
❑Experimental Technology ❑Subsidence Control fc ft
❑Geothennal(Closed Loop) ❑Tracer 20.DRIIS.IPG10G attach•additi6v2Isheetsif'tiecii
❑Geothermal(Heating/ oling Retum) Other(explain under#21 Remarks) FROM To CRn TION(color,haranrss,soiuroek a rize etc
ft. ft.Date Well Started
4.Date Well(s)Completed: O-7- Qt,-Z�Well rDA 6 ft' It.
SC-1 S J r L
Sa Well Location: Phone#: 9 --` Sy- 2L 93
Facility/04herName Facility M#(if applicable)
Qqntinif f? / c�V fat OIL e41.. NC" 7W 1
Physical Address,Ci ,and Zip �►)®D/ ft, ft —
DR Uiy
County Parcel Identification No.(PIN) —
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: —
(if well field,one lat/long is sufficient) 22.Ce cation:
3 IC N 9'0d `70 r� W
6.Is(are)the well(s): MPermanent or ❑Temporary Signa of Certified Il Contractor Date
By sio g this fort hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or o ISA NCAC 02C. 100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out brown well construction information and explain the nature of the of this record has been provided to the well owner.
repair tinder#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 Ove1'in Remarks Box).You may also attach additional pages if necessary.
drilled: I j' 24.SUBMITTAL INSTRUCTIONS
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 different(erample-3Q200'and 2©10q
24a. For All Wells: Original firm to Division of Water Resources (DWR),
10.Static water level below top of casing: V (ft.) ��ation Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: 6,
-(in.)Bit Off: r Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction methodA(4 rT'i/^L/ 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 tine county where installed
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
��f Permit Program,1611 MSC,Raleigh,NC 27699-1611 t
132.Yield(gpm) 2 Method of test: ��� ;>m 2-
o Date Site Visited: J
13b.Disinfection ° —
type 70/ hth Amount: � oz Site Visited By:
Form GW-1 �,. " - irormental Quality-Division of Water Resources Revised 6.6-2018
Price: