GW1--04471_Well Construction - GW1_20230710

WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only:
I.Well Contractor Information:
Cq D10-t7 2 J -i-e tf19►^-d) 14:WAT R ZONES£T_ .- - ..----.. -- ._ . _-.:.. . _._.. . - -
WeIIContractor Name FROM TO DESCRIPTION
' � � ._ l� 14 5 ft. 0 0 ft. 6 6 jpiA^
_ ft. ft.
NC Well Contractor Certification Number �) '.
i;._:`7, c , , �'f^ .-`Jyr 15.OUTER CASING'(frig multi=csaed Svella)OR LINER:0 s i'lii: bl'e)-_. - :
Yadkin Well Company, Inc. '-'' �' ° FROM TO DIAMETER THICKNESS MATTERIAL
Company Name J { I 1 0 2UZ3 'I-1 ft. 59 ft Cr 1 sin. -CM-a I v
1 (� J - v 16:TiNER CASINGOR�TUBING(geotbeFrneladaid I60)_.: I ' \'" .
2.Well Construction Permit#: 0 i N z q— ZO 2,. ,,,.,.,:--, 1 lr., FROM TO DIAMETER THICIOVESs MATERIAL _ - '�
List all applicable well construction permits(i.e.UJC,Cbtiry�Stotb,yydrianfe etc. % - ft. ft in. �'
3.Well Use(check well use): ft, in.
Water Supply Well: 17cSCREENi: _l: -_-- . ---_-- _ --
FROM TO DIAMETER SLOT SIZE THICKNESS MAIERIAL---
❑Agricultural ❑M�unicipai/Public ft ft in. � Y"
❑Geothermal(Heating/Cooling Supply) EResidential Water Supply(single) in. G
❑lndustrialiCommercial ❑Residential Water Supply(shared) isz,motrr - - . - - .
❑Irrigation ❑WelIs>100,000 GPD FROM TO MATERIAL EMPLAWONT METHOD&AMOUNT
Non-Water Supply Well: b ft. � ft 1 td t it/ /T /i 1 1 "Le e
❑Monitoring ❑Recovery ft. r1�Aft.
Injection Well:
ft. ft.
❑Aquifer Recharge ID Groundwater Remediation
-I9 SAND/GRAVELPACK•Crfappliiable _ _-_-__ ._. _ _ _ .__-_
❑A uifer Storage and Recovery ❑SalimtY Barrier
FROM TO MATERIAL EMPLACEME R!ROD
❑Aquifer Test ❑Stormwater Drainage ft. ft
DExperimental Technology ❑Subsidence Control -----7C ft
OGeothermal(Closed Loop) OTracer .10:D11111I!7GZOG'(atti[nLadditioiinTsheeteifi5keesssrp)T'».._ _` -_
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardneo soil/rock type grata size etc.)
Date Well Started /}r,.e./9t4..9 0 ft. 3 S- ft. .�rari f 4. t.005t sqm l
4.Date Well(s)Completed: / 3 Well ID# AA/c•' CS c 15 ft' Li ft Leive.^31 g . I-6-.1, AC k
5a.Well Location•'5aie.-a,‘,\' Phone#:�, - J4r- S' Lis ft. S�j it �rt4, ray idst,e of
Rt,,, o 61it 3,12
ft l .e r/5 i le y„I fit/k r tr"'c C✓'4,•q t 14f.e
Facility/Owner Name Facility ID#(if applicable)by ft. ft.
®`i�ti 9 V /"/16,t'6. .�� 9 ci l k0 IA 1/i(I�, l f�� ft. ft
Physical Address,City,and Zip ^-y v'S ft. ft.
I b'1
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field,one tat/long is sufficient)
22.Certificate n:
W eas,-.2„,...•-• ,..,,..-4At'Z.--- -__. Cei:1":""-Cie"°Z.
6.Is(are)the well(s): Dermanent or ❑Temporary Signa i ied Well Contractor Date
ling 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!3Vo 15A NCAC 02C.0100 or ISA 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 his 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:
S.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: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 39 (ft)
For multiple wells list all depths if different(example-3(a)200'and 2Q100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below to
24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"/P"of casing
(ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6� (in.) �`�`i ®vr o�.�3 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: A.tr R®34.r
y V
(i.e.auger,rotary,cable,direct push,etc.) 24e.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
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 D ,CCPCUA
fl
13a.Yield(gpm) Method of test: r Permit Progam,1611 MSC,Raleigh,NC 27699-1611 6�ya.,
aa oz /,i -
6/onrtkl
13b.Disinfection type: 70% hth Amount: 1'� Date Site Visited: � -r C
Site Visited By: r
Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 64-2018
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