GW1--03916_Well Construction - GW1_20230612

CONSTRUCTION RECORD (QW-1) For Intemal Use Only:
1.Well Contractor Information:
6
16 T EA-4.-,WX7Ta-ZONES
FROM TO nFSCRIPTiON
Well Contractor Name J.3'. -3oie .5m,01 4,aawe M66PI-1 6 &J'^
ft. ft.
NC Well Contractor Certification Number JUN 1 2 2023 1 15.i:OUTM:C�' G* ti-a�ikf'*eM)OR 1�if abliy--
Yadkin Well Company, Inc. FROM To DIAMETER THICKNESS kVTRIAI`
Company Name in,ofK;740'.:,I -,—�—P-7 75 1 M� ft. I ft in. 0
I:6.;DRUMCASING.'
2.Well Construction Permit 4h. -cp 9 FROM TO - DIAMETER TIZICIOZESS MATERIAL
List all applicable well construction permits(I.e.EUC,Cowity,Stale,Parlance,etc)
4- ft12 ft VinU V4 PVC,
3.Well Use(check well use): ft. ft. in.
Water Supply Well:
FROM TO DIAMETER SLOT S77 THICKNESS MATERIAL
ElAgdcultural ElMunicipallPriblic ft ft in. I -E��
DGeothermal(Heating/Cooling Supply) Dee'sidential Water Supply(single) ft ft. in.
111adustriallCornmercial DResidential Water Supply(shared)
•Mitigation DWells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT 4.1
Non-Water Supply Well: 40 ft. �b ft.
0monitoring DRecovery ft. ft. ti
Injection Well: ft. ft.
DAquifer Recharge .0 Groundwater Remediation
ElAquifer Storage and Recovery 0SalinityBarrier FROM I TO I MATERIAL I EMPLACHMENTMETHOD
E]Aquifer Test OStormwater Drainage ft. ft.
ElExperimental Technology oSubsidence Control ft. ft.
ClGeothermal(Closed Loop) OTracer "20.-3)P'1Ct-1NG1;0G,(&t&h iddltlonzl'sYfeti If hiCii
size etc-)
( , grain ,
0 Geothermal(Heating/Cooling Re��) 0 Other(explain under.421 Remarks) FROM TO DESCRIPTION color,hardness softack type,ft. f L
Date Well Started- A-,4
WdlID#4.Date Well(s)Completed: 3 )&--711 Asd 16ad
mhone#: 331'�(9--1 el 9k ft. ft t- -J.'+
Sa.Well Location:
5 f L Alilf". mo'W )k ft :"L,W%± I
Faciflty/OwndNanar Facility M#(if applicable) ft. ft.
1-6 R--3 A/, r' ve, ft. ft
Physical Address,City,and Zip I ft. ft
er
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minuteslseconds or decimal degrees:
(ifwell field,one lattlong is sufficient) 22.Certification-
0
4--1-
6.Is(are)the well(s): ff/ermanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,1hereby certify that thewell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or n341 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well ConstnLcfion Standards and that a copy
If this is a repair,fillout known well construction information and explain the nature of the of this record has been provided to the well owner.
rep
air under 421 remark 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 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: t -1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:— —J Submit this GW-1 within 30 days of well completion per the following:'
For multiple wells list all depths ifelifferent(=ample-3@200'and2@100)
10. ft 24a. For All Wells: Original form to Division of Water Resources (DWR),
If wafer level is above casing,use Static water level below top of casing: J Infbrx�ation Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diarneter:. E3 it Off: 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-163 6
12.Well construction method: W/Glo'd 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) I county enviromnental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: e/
24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
I Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gp-) Method of test: Al - Date Site Visited:�- 1'7-2 1
13b.Disinfection type: 70% hth Amount: 3- Oz Site Visited By:
U)
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
Price: