GW1--04445_Well Construction - GW1_20230710

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: •
` 14 WAl'YiIZONES >>t ii:i '�;::_-_ ''?_ "W i r_.__._'. "_
��L° �J-F �''�, r
Well Contractor Naive FROM TO DESCRIPTION
So 5 --4 q C, ft. too ft C. 6./e . Cri
ft. ft
NC Well Contractor Certification Number ---- • -- - -- •-_-
'1]S:OUTERCASING'"(fnr_mnlh=cased'weIIe):ORI:Il�It�{ifsp•lieable) �_.:_.___�.--.
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL
4-1 ft' es ft C.05 in. 5DA-aat souCompany Name 7
� Aaq L 5 ::.16lTATNERCASING'ORTQEING ffeitliermal iised-IuuP7p:.__--- . - -. :__ 3
2.Well Construction Permit#: P bpi bij 2. 2 G -CI S 9 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.WC,County,State,Variance,etc.) ft, ft in Cr
3.Well Use(check well use): ft ft. in. F
Water Supply Well: Y?'.SCREEN .,':..Y_.:..__�. �._.___ .-___ -.._.__._. .---•.-__-.- -_
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑,Agricultural ❑Municipal/Public ft ft In.
OGeothermal(Heating/Cooling Supply) residential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) L1g_Acitr['___ =v - _ 1- _-_ ___ .____ _-< .___ -_
❑lnigation ❑Wells>100,000 GPD FROM TO MATERIAL, EMPLn NTMETHOD&`AMOUNT °
Non-Water Supply Well: T r,r *., l�-, .( _ I, 'II ® ft 9 ft � dt�k��yt�� i y „ i, /a,c ,3
❑Monitoring ..•••� wr k..OR'exo`v.very ft. ai v ft /
Injection Well: ���� ft. ft
DAquifer Recharge y li I_ 1 filh water Remediation
79:.SAND/CRAWL'PACK'Crf ap)1l Belle)'
DAquifer Storage and Recovery ,CISaliraltyBllrifl& FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test ttAIC•CF•" ' ,,•I•OStdiinwater Drainage ft. ft
w:aU.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer :20 DRIfiliti'I,UG(tttriahAdditioiinl"alieettifii•rpl9ry)1:
ID Geothermal(Heating/Coolmg Return) El Other(explain under#21 Remarks) FROM TO ft DESCRIPTION(color,hardness sotllrock type,grain size,etc.)
Date Well Started u,-cft' ,® sc0 Y ¢- Lea? Rack
4.Date Well(s)Completed: / a3 well ID#A A P- c ft. ft
5a.Well Location Phone#:� '- ev d� � t) ?p j ft ,r ft &ve-ba'IC f ",e-V i ,AeJ -,�...,5
\TeJ ei9 k L a iy et e- 4414 66 ft 3 tQ it. /4.ye -f, 6,4,4 ( t7,/)A114,114'�,
Facility/Owner Name Facility ID#(if applicable)
II 2-( -C t�"{t- /9.. •
L ft. ft
. Physical Address;Cify,and Zip a111 ft- ft.
County �✓rt Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) ' 22.Cer(ific:Lion:
- C./Z,ffpe.2...e____ D 5.1 I e/6`t104 .5
6.Is(are)the well(s): permanent or ❑Temporary Si:•-. •f CeRr red Well Contractor Date
p
ting this fonn,l hereby cerrify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 1191to A NCAC 02C.0100 or 1SA NCAC 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.
repair under#2I remarks section or on the back of this form. 23.Site diagram or additional well details:
B.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-is needed. Indicate TOTAL.NUMBER of wells (add See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 09-••• (fL) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths([different(example-3 r@200'and 2@1001
10.Static water level below top of casing: 50 24a. For All Wells: Original form to Division of Water Resources (DWR),
• (ft') Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If wrier level is above casing,use"+" • �,
a 4695 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.)P I1' Oc I '• ' Program,1636 MSC,Raleigh,NC 27699-1636
•
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12.Well construction method: II<t✓' A c, " 24e.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: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) t Method of test:til`, l/10 Permit Program,1611 MSC,Raleigh,NC 27699-1611 (
70% hth i oZ Date Site Visited: 1-6 - 3 �'
13b.Disinfection type: Amount: Site Visited By: r.1 . cril
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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