GW1--05338_Well Construction - GW1_20230818

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contracttolor Information:r . •
IT
Well Contractor Name to,. ....... FROMR TO _ D TION
Q' i �'U 4 .— i D?ft. ®.?ft. ��&i / (1a t&& r f\
NC Well Contractor Certification Number �� A�f t
AUG (ft •elisl.OR L I+IER(ifap'Ile"abli) ` :5::�15:ODTEIt:CASING:for-multicase
Yadkin Well Company, Inc. (J $ 2023 FROM To DIAMETER THrt ss MATERIAL r
ini,ran in.
Company Name _n t'f^C •41
?quo
r `•;16 NNER'CASING:ORTL7BING(geotliermalcloeed=lo'o """"" 1'_N:. `•
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS Mw
List all applicable well construction permits(ie.UIC,County,State,Variance,etc.) i'•' Y ft. 1 i 6 11 ft 6. 0,r s p� ( G
3.Well Use(check well use): ,(.(�,f�tpj� ft. in.
Water Supply Well: FROM TO DIAMETER SLOT SIZE' ~THICKNESS MATERIAL
❑Agricultural ❑Municipal/Pnblic ft ft in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft in.
❑Industrial/Commercial .:l'esidential Water Supply(shared) 18 .GROUT` .
•
❑irrigation ❑Wells>100,000 GPD FROM TO MATE T4i EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 22 ft. .?1 1 1;1G �,pi pQ�ra[
OMonitoring ❑Recovery ft. ft 1� W'1 1_
Injection Well: �O'� �J
ft. ft
❑Aquifer Recharge •❑Groundwater Remediation
Ir:19;SAND/GRAVYlIPACKlif apphcatil4:2:-: :` : -•—'' e`------'-7'",',`:7?:-
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM , TO MATERIAL EMPLACEMENT METHOD i
DAquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer a:20:DR1T,ttdNGI:OG(a"itactinddition`al`sheetaif.necasary) _ =_'•" `1
PROM❑Geothermal(Heating/_qolin Return 0 Other(explain under#21 Remarks) TO DESCRIPTION(color,hardness,soillrock type,grain size etc.)
Date Well Started I/-1 lS ft. �ss f. s '! 1 L-
4.Date Well(s)Completed: �'13-?-� Well ID#AA[i' ® 717 3- --ft.- Dry � it 1 d &C4-4i ,,&ch. f icp, 5,ts�1J-'
Phone#:709 `-` a1-3 /r ft. ft
5a.Well Location: �� 1) ® !M s lPA°9 SawaItr e
Mika, ker 4o ins ft. ft. ✓ / H
Facility/Owner Name Facility ID#(if applicable) 2 ft' ft' L.
i i y/�lS 1 :t ,, Caudle, PI Wi a rk att;97 ft. ft.
Physical Address,
,City,and Zip ft. ft
�'Fi�A 6'1� Q., •:i2]::RF,IYTA"RRR:"�'_ _..,-._,...�v=-ri'G:.__„�z...., .,.._.........•....-.....__....-...._....._......___._ 4
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -}�
(if well field,one lat/long is sufficient) 22.Certification: .I
3 . //6/o N al:9 .27230 WCYYlia115:3 Co..--.- 'I 139523
6.Is(are)the well(s): ermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing 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 No 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy "t4
If this is a repair,fill out known well construction information and explain the nature of the ofthis record has been provided to the well owner.
repair under#21 remarla 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 so
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. W
drilled: 24.SUBMITTAL INSTRUCTIONS
� A
9.Total well depth below land surface: (ft.) Submit this GW-1 within 30 days ofwell completion per the following:
For multiple wells list all depths if different(example-3(g200'and 2@100)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: (i .)Bit Off: 6,O'72, 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: PI a,7 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 r
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA •,;
13a.Yield(gpm) �' i Permit Program,1611 MSC,Raleigh,NC 27699-1611
�' ~ Method of test: S- 4 If
;'>
o Date Site Visited:
. 136.Disinfection type: 7O�o hth Amount: / Oz Site Visited By:
Form OW-1 North Carolina Depattmeot of Environmental Quality-Division of Water Resources Revised 6-6-20I8
Price:_
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