GW1--04396_Well Construction - GW1_20240723

WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
I Well Contractor Information:
xr ri U-Iqe}-iG•A C T 14.WATER ZONES -
Well Contractor Name FROM To DESCRIPTION
ay SSA ft.
to 30 ft. ro Gp� ,ro
ft. ft
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wek.slOR LINER(if ripPlinable)
Yadkin Well Company, Inc. FROM TO DL+METER THICKNESS I MATERIAL t
ft. ft. in.
Company Name /) 16.INNER CASING OR TUBING.(geothermal dosed-loop)
2.Well Construction Permit#: �/ i a 7 C 2. FROM To DIAMETER THICKNESS MATERIAL _
List all applicable well construction permits(i.e.U1C,County,State, Variance,eta) ,� r ft. 113 ft V 1_S in. . In 6,I v
ft. ft in.
3.Well Use(check well use): .....‹.
171SCREEN.
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL s
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft. in. ^.t:
❑Indusirial Ste•
'Commercial ❑Resident al Water Supply(shared) 18.GROUT
❑hrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ® ft. 3 ft. Hole . l a5 PO v1'4 3 134.5s
❑Monitoring ❑Recovery 3 ft. 2 7 ft. hex G►ro it Puma L
3 7Z bass
Injection Well: ft. ft. 1
❑Aquifer Recharge ❑Groundwater Remediation
i 19.SAND/GRAVEL PACK(if applicable) \.
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD '
❑Aquifer Test ❑Stormwater Drainage ft. ft.
DExperimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if-necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Coo- a e ) ❑Other(explain under#21 Remarks)
Date Well Started e y 0 ft. 100 ft. SO,t /
4.Date Well(s)Completed: 1 34 Well ID#A4a �l/ /QO ft. I 1O ft. ere '3 re
a Rock
5a.Well Location: Phone#: 1
70
ft 1 2 ft G Can f` _
�4,#1,, 8Zy- 721-V7t)2 ft ft T y. _�l .. �..
Fv
Y - . ,;4u/ M►. ,,k l -79's-ObS'9
Facility/Owner NaAe r Facility ty ID#(if applicable) fr. ft l J L 2 _ n,
•
Rom), V LT l O�k t��inn.. X i:i� ft ft , ., ;Uri:
Ph--real Address,City,and Zip ft. ft
21.REMARKS _ v�"•
iiti el-11&_�
County Parcel Identification No.(PIN)
fib.Latitude and longitude in degrees/minutes/seconds or decimal degrees:(if well field,one latllong is sufficient) 22.Certification:
3L , `1ST N 3 1, (, a GV1 _w W1:.. -11P1a4
6.Is(are)the well(s): P,ermanent or ❑Temporary Signah a ofCert ied Well Contractor Date
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: DYes or o I SA NCAC 02C.0100 or 15A 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,
drilled: f 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 07 _(ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3@200'and 2(41100')
I 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: a (ft') Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: 6 (in.)Bit Off: to, tat e1 I 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC) 0
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: X'r /)_.) /(T^y 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) % county environmental health deparsnent of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA Vm"
Permit Program,1611 MSC,Raleigh,NC 7699-1611 is
13a.Yield(gpm) r Method of test:_ Gl 1/ g/,%, 2 mts
S'
70% huh tQ Date Site Visited: t�
13b.Disinfection type: Amount: 'e+ OZ Site Visited By:
cs
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018 ta
Price: "