GW1--03061_Well Construction - GW1_20230428

"'WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
F14.,WATERZONES
Well Contractor Name RROIVI TO DESCRIPTION
9 6
IL -3
304 ' ft. .2 '
NC Well Contractor Certification Number 16 r1t.
Yadkin Well Company, Inc. FROM TO DIAMETFd2 T13acTQrEss MATEMAL
Company Name
'OR
2.Well Construction Permit At j:: G 2.3 FROM I TO DIAMETER ITMaOMS
List all applicable well construction permits(Lq.qC�County,State,Variance,etc.) + ` 6 9 ft- '-
3.Well Use(check well.use): ft. ft. in.
Water Supply Well: ......
FROM TO SIZE S THICKNESS MATERIAL
ElAgricultural .1cp al/Public ft ft in
DGeothermal(Ileating/Cooling Supply) OWesid clnti al Water Supply(single) ft -IfFis
DlndustriaI/Commercial DResidential Water Supply(shared) T,,,3 S.,GROTj
01trigation DWells>100,000 GPD FROM TO MATERIAL ENTIACE59M METHOD&AMOUNT
Non-Water Supply Well: ft �2.2 it 9,
ElMonitoring DRecovery ft. ft.
Injection Well: P
ft. ft. XE-
OAquif6r Recharge DGroundwater Remediation rr-
19.rS AND/(MAV=:2 lClucif irp-plic 5)il 61'.":­_­1 L
OAquif6r Storage and Recovery OSalinity Barrier FROM TO I MATERIAL I EMPLACE IENTNETHOD
DAquifer Test DStormwaterDrainage ft. ft.
ElExperimental Technology []Subsidence Control ft. "-"ft
0 Geothermal(Closed Loop) DTracer
I OGeothermal(Heating/Cooling Return) l3Othar(explain under#2lRemarks) I FROM TO DESCRIPTION(color,h2rdnew,saiVrock type,grgin die,etc-)
-
Date Well Started 1 a it 60 it SoZ4
F r
4.Date Well(s)Completed: 3-JQ _9K Well]D#.4AP- m ft. it
Phone#J 1 -ZCc3
52.Well Location: 60 ft' ?keZfL 6"a .4o,
ft ft
Facility/OvinerNarne Facility M#(if applicable) ft ft.
Q'M ft. ft. APR res 2 8 2023
Physical Adds,City,and Zip ft. ft.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certification:
w
M
6.Is(are)the well(s): 9?6!anent or OTernporary Signatute of Certified Well Contractor Date
By signing thisform,1hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ElYes or MM-011, 15.4 NCAC 02C.0100 or 154 XCAC 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.
rep
air tinder#21 remarks section or on the back ofthis 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 I 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 different(example-3(a3200'and 2@100)
24a, For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"
10.Static water level below top of casing: 6 e) (ft) Information Processing Unit;1617 MSC,Raleigh,NC 27699-1617
+"
11.Borehole diameter: C� (in-)Bit Off:S-, 991 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-163 6
12.Well construction method: 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 VNIIS ONLY: 24d.For Water Wells producing over 100_0"GPD:Copy to DWR,CCPC11A,
13a.Yield(gpm) I& Method of test: Permit Program,1611 MSC,Raleigh,NC 2769-9- 6
11 A\
Date Site Visited: //_f-ZZ_+ 2-174-3
13b.Disinfection type- 70% hth Amount: 3 Oz 01 Site Visited By: � W5
i
Form GW-I North Carolina Department of Euvironruental.Quality-Division of Water Resources Revised 6-6-t,
Price:-, rA