GW1--04405_Well Construction - GW1_20230710

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor-(� Information:
a i 01011/ i-j— 4.w.grE -zons:.?ii:v ;::.::. :.....�' :.:..:: 'r. ,_ -
WellContractorNe FROM TO DESCRIPTION
®/® ft. �. ft %1 ti.
, 5-72- °aRp ft. � �.ft
NC Well Contractor Certification Number I/ !tom -.
li.OIITER:CASIl (turmiiIti"- weIIs)'OR'IINER(if a'licsliIi:);_ _:'=-• :=:"• (®
Yadkin Well Company, Inc. FROM , TO , DIAMETER THICKNESS MATERIAL
ft ft in.
Company Name 4 ti P 37 Z.-g/141 I 16 PIlYER'CASING:OR'TIIBING(geotlierinal':d'osed=loop) :;-_ -
2.Well Construction ermit# 31teii c a® FROM TO DIAMETER THICKNESS MATERIAL �^
List all applicable well construction permits(ie.VIC,Cotmty,State,Variance,etc) 7.I ft. /el ivit rt 4 S. ° Cr A l v F.
3.Well Use(check well use): ft. it in. r,
Water Supply Well: �p
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL LA
❑Agricultural ❑M •'cipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) "'"dential Water 1 (single) ' •
� !� g PP Y) "' Supply ft ft in.
❑lndustrial/Commercial F.•..idential Water Supply(shared)
;18i:GROVTJ'
❑laigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: e) ft' g` ft' /301-cia0 po ule i.....-0,
❑Monitoring ❑Recovery 9 - ft a..'ft Ueo, ,s'i„v1-a1 et,a+vr"e/
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation __
❑A uifer Storage and ❑Salim Barrier ,FR SA1VD(GRi4VELPACK{Mif ATE IAlile)`, :..
Q g Recovery tY FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stommwater Drainage ft ft.
❑Experimental Terhuology ❑Subsidence Control ft. ft. 17,
❑C-eotbennal ClosedLoo ❑Tracer ":20:DRII,'tS1VGLOG-1ttai]riidditioiialehutiifne'c-ess" - - - -_ _
( P) ( cry)� . - CZ
❑Geothermal(Heating/Coolin Retum) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soli/rock type,grain size,etc.)
Date Well Started / 3 v �;b ll) ft. �� 'ft s o yy�
37
4.Date Well(s)Completed:te9, 3 Well EN��r ,,/ y0
5a Well Location: Phone#: 2.3C.14,y -39or ft. ft
6:
S'iCj,'xtiwJt •C 4/ ft. ft. �A`'M a,..t/...r r-` '' h�t � -'?4
PIA Cott O4e Y\ ft. fit. mow.
Facility/Owner Name ��tr✓/ '' ^^ Facility ID#(if applicable) g
g 74 &(1� + i'< � al 5 r / �°
t O ft. ft. r J U L o 9 -l1123
Physical Address,City,and Zip 4�"n� ft IIRCiFf::Si:;.-2n ;:-.7•.^
Al•(ei k. h _ _. _ .. -_�-_,_ -_ . -:,-.: .�1 t t� _
County X. Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: .
(if well field,one
e lat/long is sufficient) 22.Certification:
3c. lJ-e / 3 fit' V N r�0.. Q go- 4 w
6.Is(are)the well(s): ermanent or ❑Temporary Sign of
Ceir Ai 7t174114' 'Well Contractor Date
By signing this form,I hereby"certify that the wells)i t(were)cons -ucted in accordance with
7.Is this a repair to an existing well: ❑Yes or Iti ISA NCAC 02C.0100 or 15A NCAC 02C.0200 WellsConstructon 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 solder#.21 remarks 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 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: 4/3 c (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3Qa 200'and 2@I 00')
° , 24a. For Al]. Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 60 (ft Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 V.
If water level is above casing use"+"
11.Borehole diameter: G (in,)Blt Off: 6•I b5" 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC) 4
Prograzn,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: :e 164r7 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 Tki
(2
FOR WATER SUPPLY WELLS ONLY:-,t.•. • _ 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA -.1'I
13a.Yield(gpm) 0)-
Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611 I.
��' Au,a c(4.f 1 f i ei.ve tin
70% th Oz Date Site Visited:L-tt-2 ��-�, .
. 13b.Disinfection type: h Amount: /1 a7 Site Visited By: h 9 ,f-d
G
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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