GW1--06972_Well Construction - GW1_20241118

WELL CONSTRUCTION RECORD (GW-1), For Internal Use Only:
1.Well Contractor Information:
c-O'mein ..n1 1J)1®)
Well Contractor Name FROM TO DESCRIPTION
NC Well Contractor Certification Number ,;15°OUTER"CASING(f6i'iniilti"casediieliil:OR LINER gip"ticable)`--.::: _:,'.:.:::: — )
Yadkin Well Company, Inc. FROM TO DIAMETER _THICKNESS
1 MATERIAL
ft. ft. in.
Company Name
Li r 9 r i :16:11e1 R.CASING:OR.TUBING:(5 eoth-er-MU eloied:loop): :�__
2.Well COnStrnCtion Permit#: 00 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.IBC,County,State,Variance,etc.) • I ft. 7 ft 1 !i I>r WOW pre,
3.Well Use(check well use): ft. ft in.
Water Supply Well: L'Ill Salim'--
uPP Y FROM TO DIAMETER SLOT Sr7I, THICKNESS MATERIAL
LiAgricultural ❑Municipal/Public ft ft in.
1 OGeothermal(Heating/Cooling Supply) *esidential Water Supply(single) ft ft. in. P
i ❑Industrial/Commercial ❑Residential Water Supply(shared) — -
• ."18::GROUT,_
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: ( fr' 3 c ft • trl�'7{� pa ft?, ....3
❑Monitoring ❑Recovery ft ft tr r i c) BO
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation
iVa SAND/GRAVEL PACK(if:npplicable)... _ _ _ __._.._ — . -
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLAt'EMENTMETHOD '
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology 0 Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20iD11I1S NGI;OG(attacliudditionalsbeetiif.aeceasary),= __:_ _____ __
FROM TO DESCRIPTION(molar,hardness,sell/reek type _.-
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) Brain size eta)
ft. 67ft
Date Weil Started r SD 1 1i"�! >'!6/ `,
4.Date Well(s)Completed:® 02,-3C Well ID#AAV P 4( d r t t' A ':7 p'j j pre 7 ., �"
5a.Well Location: Phone#: 7o'/- qo -cS°'66 ft. ft I
ft ft
le f.,ni grauef -, _ ..... , ° ,
Facility/Owner Name Facility ID#(if applicable) ft ft.�I
fill ice- ,'v n FI ve& ft. ft NUV 18 Z(24
Physical
alll Address,City,and Zip ft, ft
County 5•, Parcel Identification No.(PIN) //��t� 3� i+S �@' ''a• �
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: p
(Ewell field,one lat/long is sufficient) 22.C r i Lin:
36' dos 31i6 N %Ia 10° c q " W I6�-2�' y
6.Is(are)the well(s):0Permanent or ❑Temporary sign. C ti ll"C85tractor 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 *To ISA NCAC 02C.0100 or 15A11CAC 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.
repair under#II remands section or on the back of this form. 23.Site diagram or additional Well details:
You may use the back of this page to provide additional well construction info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
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: 1 / 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 dierent(example-3 00'and 2@100) '
Q 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water Ievel below top of casing: 4 (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+'
6
11.Borehole diameter: (in.)Blt Off: 4 o y 24b.For Injection Wells:Copy to DWR,Underground Injection Control gm)
Program, MSC,Raleigh,NC 27699-1636
12.Well construction method: G.il,! O")) n 7 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
13a.Yield(gpm) Method of test:
�r ` Permit Program,1611 MSC,Ralei h,NC 27699-1611
70% hth ��
Date Site Visited: IS/-a A
13b.Disinfection type: Amount: � OZ - Site Visited By: �•°
Ci •
.....„,
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018 v.,
Price: Ult. C.,4 a'erkA, _ ( \ �` 1
632J - st f9 Yc.«G+ `4 r