GW1--04443_Well Construction - GW1_20230710

ALL CONSTRUCTION DV -1 For Internal Use Only:
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1.Well Contractor Information: a°
?�(2 /C7 V�,P • 14.WATERZONES::..':.. _ - > y,;,:.:� ,
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FROM TO DESCRIPTION
Well Contractor Nmee . `
"lv3V - / 'f�ft. ®yg_.ft. l. dper
f. ft
NC Well Contractor Certification Number :"15:OUTER CASING(fariculti liseavieU)ORLINER:(tfap'Itaile).:=_'-_ '
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS IWATERIAL '
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Company Name, 3 •46 i- r 32,T" '/-•! ft. 11'6' ft. 6,.r --.6. in. spa-al PV C i
v l_16: EER'CASING'OR.TUBING(geothei°mdmal' 'd-l6op)_--_ __ .. C
2.Well Construction Permit#: A R.Wa�L. 2-02.-3 0 r r 'INN FROM TO DIAMETER TtT.efINFSS
List all applicable well construction permits(i.e.UIC,County,Slate,Variance,eta) ft. ft. in.
3.Well Use(check well use): ft in.
Water Supply Well :_17•SCREEN..:i :.. - - - -
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS: AL _
❑Agricultural ❑�M,/unicipal/Public ft ft in.
"'Geothermal(Heating/Cooling Supply) ll esidential Water Supply(single) ft in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) motri - - --- . ---
❑Irrigation PWells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply We ({:.w y 1 r I /( f
PP Y �:.-...o`�'i � y -•:�,.r � f t �� ft LLir'I r.:I i'c(tip f�°)1 O�� �va a+L
❑Monitoring r''`�` IL.; ° L - ❑Recovery ft. ft.
Injection Well: '' - ft. ft
❑Aquifer Recharge J,3_ 1 ���� ❑GroundwaterRemediation
2191SAND/GRAVEL PACK(if flialia le)`_---_- ----` _--- -_- -----
DAquifer Storage and Recovery,,•,_..-F f,:;:::�;' IDS iifiity Barrier FROM TO MATERIAL EMPL&C tOrErRon
r'l ` •,,,-<:, ft. ft
❑Aquifer Test ln;;II', (' y.�;3; Drainage
❑Experimental Technology OSubsidence Control ft.
"'Geothermal(Closed Loop) "'Tracer •10:'7DRIliI3t4G'LOG:(attach.sdditioual'iheefsifiiecessaiq):___: _
"'Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soil/rack type grain size etc.)
Date Well Started '_,A,-c 3 �+ 6 ft. 6 0 ft. �o i I 16 cv5.e /S�L,_� �"
4.Date Well(s)Completed:; Jw�l Well ID# ®C"J 7�y ft. lout ft. L.-Art/5 (fa,e-y' d- pa6.7�4�"i t(/at (c. /"'e'�
5a.Well Location: Phone#:33C 'Y-Y#�P `�j ft. 191 ft 64-c_y Rt,L/-�15 �c 4-o C7,4
�$/ „3,��®X �Q✓- 6� rise tt /6bft fo."ZI-es•S l.�abr4.), S a,(-, 9- ,,,
Facility/Owner Name Facility lD#(if applicable) jt,e, ft. ^d�ft /'of. -k /+ y /r�1
I ft. ?(� ft (� C�s� t'f U
Physical Address,City,and Zip ft. ft
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field,one lat/long is sufficient) 22.Certificati,n:
i, n
�(, , Z e 30 Re''' N t 1 76, � fit'& 1'��,1 O Y
6.Is(are)the well(s): i�ermanent or ❑Temporary Signs edt r d Well Contractor Date
6. 0. ng 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 I�}No NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction informatidn and explain the nature of the of this 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.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-I is needed. Indicate TOTAL,NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: I 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: g t. (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2(g100)
10.Static water level below top of casing: ge, (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If venter level is above casing,use"+" • Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
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11.Borehole diameter: 4_� (in.) 1 -i.� 0 c>s t'O3(! 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC'2.7699-1636
12.Well construction method: rr.es gp \
(i.e.auger,rotary,cable,direct push,etc.) / 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the H
county environmental health department of the county where installed
Z.
FOR WATER SUPPLY WELLS ONLY: a <
24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611 d
13a.Yield(gpm) q.-5Method of test: At'f iLtmil 1 54 �� 1
type: 70% hth Amount: VY Date Site Visited:3' 2 2-2.3 �� tvv
13b.Disinfection aOZ Site Visited By: n.g s �,�-f ej
Form GW 1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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