_Well Construction - GW1_20230315 (52)

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
• � e-y '-14:WATER'ZONES�i�:=: :_..� ::.:»,�� -'--'-- •_-''-�_._.. ._ -.. __ . -- -
Well Contractor Nam�eg �p FROM TO DESCRIPTION ® ry
��[y 'fir t P 671°d'�/ rf�i•C1f' .
ft. tt
NC Well Contractor Certification Number
"]SCOUTERCASINGTfoi•-mnitiFcased:weIIe AR•I';INEIT�tfa'•'licable :-_.`;"'.."=='-::`
Yadkin Well Company, Inc. FROM TO DL4htETER TffiCMMS MATERIAL
ft. ft in-
Company Name
:16 Il0MXCASING'OR:TIIBING
2.Well Construction Permit#: 0 FROM To DIAMETER Tfflao ss MATERA.L J
List all applicable well construction permits(.e.UTC,County,State,Variance,etc.) ft. ft, ° on,
3.Well Use(check well use): ft ft in. A
..::.
Water Supply Well: _ _
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft
❑Industrial/Commercial ❑Residential Water Supply(shared) -
01ni ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENTA=OD&AMOUNT
Non Water Supply Well: ft ft ��-� A-;
❑Monitoring ❑Recovery Q ft. ft. t'Ge S�1trr C
Injection Well:
ft ft
❑Aquifer Recharge ❑Groundwater Remediation -
19a.SAND7GRA.vEI;PACF{,
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer .20iDRII:TML,OGr attachadditibni ihi tsifueee5
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21Remarks) FROM To DESCRIPTION(color,hanu soillrock size,eta)
Date Well Started -`S�� S ft '®° L nr
4.Date Well(s)Completed:�A 5-•.13 Well M# 3sft. 0�
5a.Well Location: Phone#!(• ZU- q/ —O f'13 ft. ft
I )a 676 VU IV,.rC3 P 1 ft ft
Facility/Owner Name Facility M#(if applicable)
ft. ft
i�ri 1 �n y
ft, ft I � L I.i 23
w•� Physical Address,City,and lip 9 ft ft
1� County w$/ Parcel Identification No.(PIN) et/ oal ' . 'Fe 0A., aa waceeas
p C.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: L+
(if well field,one lat/long is ufficient) 22.Certification: g(�
N $3r ®.3, JS W r
6.Is(are)the well(s): ❑Permanent or ❑Temporary Sl e of Ce}t•red Well Contractor Date
By signing thisfonn,I hereby cerhfv that the well(s)was(were)costmctedin accordance with
7.Is this a repair to an existing well: ❑Yes or InNo 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction itfornnatidn and explain the nature of the ofthis 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.Far 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 I GW-I 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
0
9.Total well depth below land surface: P (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(ezmnple-3 a@200'and 2@1001
a 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 1� (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
IJ'water level is above casing,use"+"
¢ � o e �,_� h.For Iniection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: Cn•) tad` @@11 Program,1636 MSC,Raleigh,NC 27699-1636 �(
12.Well construction method: % R-640<Br 24a For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i a 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 V
/��9 Permit Program,1611 MSC,Raleigh,NC 27699-1611 1
13a.Yield(gpm) �� Method of test: m'�AL 6% d a
70% hth . oz Date Site Visited: a-a 4- � ����
13b.Disinfection type: Amount: Site Visited s/,l
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-201a8�
/ Price:,