GW1--04376_Well Construction - GW1_20240723

CONSTRUCTION RECORD (GW-1) For Internal Use Only:
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tra to Information:
,/ L( 'frA v w`V't- 0.4:WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
(� fgq ft. iq0 ft
3 1�
v 4 ft. ft
NC Well Contractor Certification Number 15.OUTER CASING(for m'tilti-caied wells)OR LINER(if a licable)
Yadkin Well Company, Inc. - FROM TO DIAMETER THICKNESS MATERIAL
ft. ft in.
Company Name
�.���•- '16.INNER CASING OR.1 UBING.(giethermal dosed-loop)
2.Well Construction Permit#: LI u FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) !/ ft. rf 7 ft. C.12-r in.
('/10 2-( P Vc_ -
3.Well Use(check well use): T ft. [ ft. (1 l J in. 13 V R
'Zifj
-
Water Supply Well: "SC
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaliPublic ft ft. in.
❑Geothermal(Heating/Cooling Supply) )(Residential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18_G• RODT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 3 ft l�n L•4 t ' CL�pS 9k/el I?
❑Monitoring ❑Recovery _3 ft. f 6 ft. t�,f i Ai!t (l v'-r (o"w / p3
Injection Well: ! J n TJ l 7 { �f �( D C�J
DAquifer Recharge ❑Groundwater Remediation 9 ft. �16 ft l�T�� `F1 CA
{�s�!} ea wr,� !r f'
1'19.SAND/GRAVEL PACK(if applicable) Y, V1
DAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft pq5,,
❑Geothermal(Closed Loop) ❑Tracer 20.DRI))INGLOG(attacliitadittena7 slieeti if necessir"y)" 190")
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM Oft TO ft DESCRIPTION{(color,hardness,soiVroek type,grain size,etc.) /
Date Well Started -?Li 1 Li //}} l -�O,1 -
4.Date Well(s)Completed: G►]k-'.il Well ID#A4a�Q/'t 3 rt.ft. }Tf ft re(
I (�I v 2024
Sa Well Location: '/ 1 Phone#: 70 i/•- y 7(/ �1l fi�r i O ft. /4�1 ft. /'O ' 1
pp e V t1Cty1 Ies . ft. O ft so 1v.-,.-: ., '-) ---
Facility/Owner Name Facility ID#(if applica 7{1 ft q{..fZ ft , ` / L
0 3°?3 £ +L 50 P.a &)Cnt.,r agbo�' ft. ft
Physical Address,City,and Zip ft. ft.
21.REMARKS E`
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one las/ sufficient)
long is 22.Certifrcatio .
3 �,s- ' qi;: 'N g i 0
38'q '' W 6'-)-6-1K
a
6.Is(are)the well(s):XPeranent or ❑Temporary Signature of Certified Well Contractor Date
m
0 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: ❑Yes or XNo 15A NCAC 02C.0100 or 15A NCAC 02C.3200 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.
�f\i repair under#21 remarks section or on the back of this form.
(1 23.Site diagram or additional well details:
��J/ 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- is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: l 24.SUBMITTAL INSTRUCTIONS
j
9.Total well depth below land surface: 42 (ft.)
For multiple wells list all depths if different(example-3@200'and 2QI00') Submit this GW-1 within 30 days of well completion per the following:
t 24a. For All Wells: Original form to Division of Water Resources (DWR),
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: gj (in.)Bit Off: ‘+ 1/U/>
7 24b.For Injection Wells: Copy to DWR,Underground Injection Control(TIC)
Program,1636 MSC,Raleigh,NC 27699-1636 .,....7
1
12.Well construction method: Cil "ce f ar 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 depan:ment of the county where installed �%
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA F-
Petmit Program,1611 MSC,Raleigh,NC 27699-1611 •T
13a.Yield(gpm) Method of test: /`/3 A//' a
° Date Site Visited: 1.2 - .2C-� 3
'
13b.Disinfection�ec type: 70�0 hth Amount: OZ Site Visited By: ti1 6
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
Price: