GW1--00560_Well Construction - GW1_20240125

v'Lv�CONSTRUCTION RECORD(GW-1) For Internal Use Only: .
®'1,Well Contractor Information:o 1
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J �fv 1 `� `„,14MATFOZONES3 c:,.. -,--1-1.,4-: _•1:,:ra, y;r� ., ,-»-:'-r.7�,^t
FROM TO ` ;;R,
DESCRIPTION
Well Contractor Na it ft
�j • 2,37 ft. 7 ft $1AP I/ Vyei A ,',3. r,
NC Well Contractor Certification Number w15.'03u :CASING'(for'multi-iiied:weI OR LINER'(ifap licab7er-17 .s:7:
Yadkin Well Company, Inc. FROM TO _ DIAMETER THICKNESS MATERIAL
ft ft in.
.1..•n-.`-..ter-�`.-:t�`�.`.�.1 Company Name i16rIIQNFRGASING.OR'..uBING(j�entiie lifal'cloiied=loop):'tie ,
�9 l-g� FROM TO DIAMETER THICKNESS MATERIAL
2iWellConsbr wells Permio#: (i ,i,1• f�7 ft p o0gcc'in. sp )® p
List all upplicrible. construction permits(e.e.ine,Camay,State,Variance,etc) ��1 6S'
ft ft in.
3.Well Use'(check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Pnblic ft. ft. in.
. OGeotheimal(Heating/Cooling Supply) 1tesidential Water Supply(single) ft. ft. in.
❑Residential Water Supply(shared) ,,,.;-z-- - -__ - ,._--.___.�_.____.— �:
❑IndustriallCommercial. `18 GRGUI'G. ��-.�._� ..--.,,_. -..._.___.�=_ti_�._. �-_-.-.-...___
❑lni ation ' ❑Wells>100,000 GPD FROM TO MATERIAL` w EMPLACEMENT METHOD&AMovNT
i1 Non-Water,Supply Well:, 0 R i ft. den,egia, ity00 eel D
OMonitoring _ ❑Recovery S' ft. 5'r ft fie,ea.,.sht9'ej e1mpexl
Injection Well:• ft. ft
❑Aquife"rRecharge .❑GroundwaterRemediation
1119::SAD/GRAVEL'PACK(ifiFil calle)y..�'_= _;`:`.«w-`i.:�,. -,.=.. . C?
❑Aquifer•Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD .
❑A uiferTest ❑Stormwater•Drainage D• ft. P(
9 •
,
❑Experimental Technology.' ft. ft❑Subsidence Control __
OGeothennal(Closed Loop)oop) OTracer 1r2ll;DRIVING1:OG•(ittach adiiiti`onaI"si eetiti.necessary)i. 11 -
FROM TO DESCRIPTION(color,hardness,soWroek type,grain size,ern) .__.
4 ❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)4' Date Well Started.it a.,_ 3c- e' 0 ft
/� 1?-0 '�
4:DateWell(s)Completed;. p)...6 c)® 3 Well ID# G""�9a2 9 9?Pft .fC"t hie �✓•: ,-�
Phone#: , ft ,ro ft r�y1,9 �
t 5a.Wel1 Location /° !f°f +®
� I .I 1 r cl� ft bed ft. eel A�'
w � i.: . , ;
Fan ty/0wnerName Facility ID#(if applicable) ft. ft �itl for i�r
,',. ..,,,,," -1 _._ 4'i,,k..5 cd Vek, '..,, , A Olie' ft. ft. e----,:.
v' Physical Address City,and Zip ,231Art _ M
6 i O r !Pit;REMABICR;;i '«r-:�:_.. z-.-1?Y;.•.,. _1" ---::::::3 6 --.
_ r� .I �vtv.�
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County Parcel Identification No.(PIN) '' g�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field„one latllong is sufficient) 22.Certification: ✓✓✓
�...�n L4 fI N u • t�f� W �� +•
®�y�' � . \-/
6.Is(are)the well(s): Permanent or OTemporary Sigca. of ertifia ell Contractor Date
re-
By signing this form,Thereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or I No 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fell out known well construction information 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:
$.,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,,Gyl is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
chilled: -:' 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 406 (ft") Submit this GW-1 within 30 days of well completion per the following:
Far multiple wells list all depths ifdifferent(example-3@200'and 2@100')
les 24a. For All Wells: Original form to Division of Water Resources (DWR),
10:Static water casing,
elow top of casing: �r (ft") Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use'+"
11'.Borehole diameter:- ' Z (in.)Bit Off: 4 a 075 24b.For Injection Wells:Copy to DWR,Underground Injection Control(lUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12:Well construction Method: e7/2,14,‘ ' 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: 24d.For Water Wells producsng-over 100,000 GPD:Copy to DWR,CCPCUA k
,t Permit Program,1611 MSC,Raleigh,NC 27699-1611 C
13a.Yield(gpm) .. ' ,Method of test: sd R
Date Site Visited: /I—1,.a.� Y t..��
'` 70% htFi:' `'
13b.Disinfection:type: . - Amount: a t o OZ Site Visited By: g,. ' :
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018 qy
vni e.s. .dam - • .s_ _� __-✓t�
Price: -duel•
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