GW1--03946_Well Construction - GW1_20230612

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: ZA
1.Well Contractor Information:
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Well Contractor Name FROM ^PTO f DESCRIPTION
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NC Well Contractor Certification Number 4 0 Li ft 406 ft
'ls:'OUT,ER'CASING(fdrinidd-'a&d'v iMIORIdTlER'(if's
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft in.
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Company Name
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2.Well Construction Permit#: WS 0 1®®®�� i;16:IIaTER•CASING=OR'.TQBING: eotberinal'dos@3=1o0•";--_-- _ _;- 1
FROM TO DIAMETER THICKTVFSS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft ft. in
G P
3.Well Use(check well use): ft. ft. in. ®� s • t OL
Water Supply Well.: --
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
[]Agricultural unicipal/Public f ft in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft �•
❑Industrial/Commercial ❑Residential Water Supply(shared) >:18%GROUT =
❑Ini ation ❑Wells>100,000 GPD FROM To MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ® ft-
6' ft
❑Monitoring ❑Recovery ft. ft 41
Injection Well: S
ft ft
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier R'SANK/GRT!Lr MATERIAL
EMPLACEMENTMETHOD-
❑Aquifer Test ❑Stommwater Drainage ft
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer 10:DR1TLV ZOG dttacliadditiuna]'slieetiifndcEss` - _ __ _
❑Geothermal(Heatin C ling$etum) ❑Other(explain under#21 Remarks) FROM TO DEsca PTION color,hardness,solllrock typk grain dze,eta
ft
Date Well Started • ft Sol,/
4.Date Well(s)Completed: 41191 3 Well ID# P ft. 6.5— ft- e, U
spa Well Location: Phone#: CS, fL y®G ft 1& 6r c
/OWn 0� r,AA ft ft
�jFacility/Owner Name Facility ID#(ifapplicable)y p�/ ft ft r.• i .; t ,,i
c i aC-7 ft L t e, �"� S&ks ury, oq 8 1-I fry ft ft
Physical Addifess,City,and Zip a ft. ft 1 u 0
23
County Parcel Identification No.(PIN) a '
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell held,one lat/long is sufficient) 22.Certification:
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6.Is(are)the well(s): rmanent or ❑Temporary Signature of Certified Well Contractor ate
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: ❑Yes or Va 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and explain the nature ofthe of this record has been provided fa the well owner.
repair under#f2l remarLz section or on the back ofihis 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: WA p / 24.SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: /V b (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if dierent(example-3Q200'and 2Qa 100)
�] 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water•level is above casing use"+
f Static water level below tap of casing: 0 (ft•) formation Processing Unit,1617 MSC,Raleigh,NC 27699-1617
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11.Borehole diameter: !J (in.)Bit Off: 7, _197 24b.For Injection Wells: Copy to DWR,Underground Injection Control(NC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: T�� Lit t r f»I-I P„ d
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: 300+lf l
lr 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm)
160 Method of test• �4 0 V nV Permit Program,1611 MSC,Raleigh,NC 27699-1611
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70% hth V Date Site Visited:
13b.Disinfection type: Amount: ��. OzSite Visited By:
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Form GW-1 North Carolina Department ofEnviroamental Quality-Division of Water Resources Revised 6-6-2018 —1
Price: