GW1--05229_Well Construction - GW1_20230818

- WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Inform/action:
3- .i:. ea) �/ I °1 , f-z4_w:�.'r. zoNEs _, ._.._ : • , . _ -. . .. ..We1lContractorName FROM TO _DESCRIPTION p---
1 °� 9''ft. ft
,j NC Well Contractor Certification Number '15i:OUTER:CASING'(for multi=cased"weIIS):ORI:TNER(ifaP livable)CL:_ '•S::i:z.&; )rj
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
- Com an Name k 6 3,X. - 7 I-3�
P Y �-/t ` � i16E'INNER CASING:OR.TUBING:(geotherm`al dosed=luop)'= =_ Qt
'2,Well Construction Permit#: 0 T3 itc a) FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) •Al ft 1 0 ft )„ tilt ' ;j asttAmited d
3 Well Use(check well use): ft ft in.
�
Water Supply Well: Zi. SCREEI!),;-'__._:` -_- _ _ i l;
pP Y FROM TO DIAMETER _SLOT SIZE THICKNESS MATERIAL.
❑Agricultural ❑MunicipaliPublic ft ft. in. D
❑Geothermal(Heating/Cooling Supply) l<esidential Water Supply(single) ft ft. _ tn. vct
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑lnigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 1 ft )14 1 ft 1 A:h 91 aAl CA-
❑Monitoring DRecovery ft. ft.
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation ..,i 19SAN /GRAVEU-PACK-ifspplicable). .� DI
, .v
[Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD ' - (A
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft
.---
:Geothermal(Closed Loop) ❑Tracer :20:DRIj;ETNGLOG(attach'additional'sheetsifneceivary) _.. L�.q.•q
FROM TO DESCRIPTION(color,hardness,seillrock type,grain size,eta) 1 II
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft. 9
Date Well Started qc-)-a, � O i 7 1
4.Date Well P�]Well(s) '`'4s Well ID# AAi-^779 11 ft qq. ft Si -i-1 :lba 601 i
Sa Well Location: Phone#: Rt'l-3I'7- Yr'�7 45tie / ft. /Ia.ft ` fir pli f'
C41 Ly cfeloriffi rte- eroN �aL +q gym, Ell �6? f &f '°-
C Z
Facility/OwnerrN�a�me Facility ID#(if applicable) 401 ftiSCX ft MOhart) Vevir 8my i9YtA Uit
C[a ate- 9®� b`� , Pi Qf`gy ft ft.
ft. ft it
Physical Adddress,City,and Zip
County Parcel Identification No.(PIN) AUGb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: H U ll 202
(if well field,one lat/long is sufficient) 22.C tificatton: J
• ,3C 31.3 N 51. l 3 7 2.9 Rt trfi,a; n+G, $�' �..
� Signatur C ed Well Contractor Date
6.Is(are)the well(s): l�Permanent or OTemporary
By signing this form,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or 15A 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 information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remark section or on the back of this form. 23.Site diagram or additional well details: - , ._. , .21
You may use the back of this page to provide additional well construction info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-1 is ngeded. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages:if necessary. (�
drilled: ® f{�
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: geo (ft.)
For multiple wells list all depths if different(example-3(a)Z00'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: i Il (ft') Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" `�,
11.Borehole diameter: C (in.)Bit Of: 54 `i 24b.For Injection Wells:Copy to DWR,Underground Injection Control(RUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: L r 'Q O ""Cl ni, 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: r. 24d.For Water Wells producing over 100,000 GPO:Copy to DWR,CCPCUA :
A ° Permit Program,1611 MSC,Raleigh,NC 27699-1611 '
13a.Yield(gpm) I Method of test:
Site• o Date Visited: -57- -71 e -A ea i,
36
13b.Disinfection type: 70�o hth Amount: OZ SiteVisited By: 3w. t
A1
Form GW-1___ _. North Carolina Departmgat E of_nvi o nmeatal Quality-Division of Water Resources Revised 6-6-2018
Price:_ i