GW1--04388_Well Construction - GW1_20240723

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: 3
1.Well Contractor Information:
Jc,„1,ei 144(1 t (7,14.WATER ZONES
Well Contractor`'// Namet FROM TO DESCRIPTION
0 1 [�21(Q ft. 2[f 3 ft. C t:' �` I9?Th
(NC Well Contractor Certification Number ft ! L �0/j. �'11
15.OUTER CASIN (fdi mufti'-'e7ese wells)OR LINER(if ip li.... 221e)
FROM TO DI. ER Tffi MATERIAL
Yadkin Well Company, Inc. :
ft, ft. is / (p
Company Name ',,d 16. CASING OR HIRING(geothermal dined-loop) /
2.Well Construction c Permit#:
I Y FROM TO _I DIAMETER CRNFSS MATERIAL
List all applicable well construction permits(i.e.UM,County,State,Variance,etc) ft . ell T 6 42 Sd,' 21 tot#6 Z
3.Well Use(check well use): ft. ft. n. I
W ter Supply Well: �'S I ��" "
"'FROM TO D R SLOT SIZE THl S MArrXuer,
bicultural ❑MunicipallPublic t. ft in. I
y
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ( �
ft ft. in• 111
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM 1 i MATERIAL I EMPLACEMENT METHOD&AMOUNT �,
Non-Water Supply Well: 0 ft. ( 0 C k'S (9rUst, /'1fr U.br446 S
❑Monitoring ❑Recovery ' <.' ,7`L ft. 0)
Injection Well: .s 0
:
❑Aquifer Recharge ❑Groundwater Remediation ft. _ ft
I
❑A uifer Storage and Recovery ❑Salmi Barrier 119.SAND/GRAVEL PACK(if applicahle)
Q g erY ty FROM TO MAT EMPLACEMENT METHOD
DAquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLINGLOG(attach additional sheets if necessary) (
❑Geothermal(Heating/o',^t;^^n eti•-..\ ❑Other(explain under#21 Remarks) FROM Tq� PT SCRIPTION(color,hardness,soil/rock type gain sire etc.)
Date Well Started_ . -.>rr�- -I�' r'' ft' _ 1'� SO' I
4.Date Well(s)Completed:
�� Well 1D# /4r,�'7'(14. q.2 a 4,5 d r„,14, of ram so edr-
5a.Well Location: Phone#: 33‘- 41..(J5/A r26,55ft. 37j f. d'1i �► Tin rock_ t4cd -
/,;."1 L,A st£/ �i f i%4 S' ` A/./ rye-- `'et J t�!S ft. /JG�ft. ` t(���- .10„)
,'i 106M- la
Facility/Owner Name ✓�/ Facility ID#(if appli able) u IV ft. 5(a!v2fr' ✓(.ir{l_ kzx i h,re
ft. ft ,[��
,Soiii), ,Itt...:4,0_, Apt A fl;iltP; Ci,u.1(
Physical Address,City,and Zip ft. ft
/ /. ', ;11:REMARKS.,.
pi I; 17 0)
County Parcel Identification No.(PIN) I .C_.s._A►.-.. Of ;,{_ . �.,p
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I'I I 2 r'6?'t ��/
(if well field,one lat/long is sufficient) 22.Certificati9g: J L
3t : a571R N a1, 24Z13 J w � -- .. ,;6, 12--2
6.Is(are)the well(s): Oermanent or ❑Temporary Signature of Cert fled Well Contractor Date
N
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 tic() ISA NCAC 02C.0100 or ISA NCAC 02".0200 Well Construction Standards and trust a copy
If this is a repair,fill out known well construction information an' plain the nature of the of this record has been provided to the well owner.
repair under#21 remarlaa section or on the back of this farm.
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:
��� 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.)
For multiple wells list all depths if different(example-3Q200'and 2(a3100) Submit this GW-1 within 30 days of well completion per the following:
2C 24a. For All Wells: Original foam to Division of Water Resources (DWR), 0
10.Static water level below top of casing: S (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" G �yty
H.Borehole diameter: 6 (in.)Bit Off: , . O .5 k 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC) !��
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: i'f
J'i 7f 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 , .
'
(gpm) 5-0 Method of test:13a.Yieldc2 jA i Permit Program,1611 MSC,Raleigh,NC 27699-1611
70% hth IS! OZ Date Site Visited: !,2 -f'--2. 3
13b.Disinfection type: Amount: Site Visited By: (/13
Fomt GW-1 _ North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018