GW1--00757_Well Construction - GW1_20240131

W' L CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: __ ‘ .
-5 6 , y t i 1 i c /`1, f°7 Lt 1'v s' J r. t::WATERZONESe :S:H i' '_I I: :,7: .
FROM TO DESCRIPTION
Wellll to
Contractor Name
_6 � Kf'� � r 1S` G� ft. � �1� ft �f` i 3 y� ��i„QP
ft l7
NC Well Contractor Certification Number fIS::OBTER•CASING'(form`ulti=cased wells):OR-I.INE.R(if,a`IfE111)= 3:3'.
Yadkin Well Company, Inc. FROM TO DIAMETER - THICKNESS MATERIAL �,
Company Name •, j ft t Z ft G.f 5j. in. DR.�'� $'ldf-2t PvC
s,,o Q Q- g g '16-H' R:CASINU G:OR:TUBING(g btlierma1 dosed;ldop)i=t-;'6�`- -=:„S:.. :"
2.Well Construction Permit#:tip►'.S i le 0 R 'I a c- 2.42.3 FROM TO DIAMETER THICKNESS MATERIAL. -
List all applicable well construction permits(Le.UIC,County,Slate,Variance,etc) it ft in. Q
-
3.Well Use(check well use): it it in. I.
C`
Water Supply Well: a 771:S.CREEL° T;_7__�= - —_ - f-_•
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑�M,/unicipal/Public f. ft in.
❑Geothermal(Heating/Cooling Supply) ildResidential Water Supply(single) ft. ft in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) ::.18s:GROUTi-:__ __... _-_ - __ -- --------.-,"-_..
❑Irrigation T -- 'r ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT CP
Non-Water Supply Well;:;e ,` - ,, b/ a ° ft.
Z 0 ft C i.o f e�
%, �194wf GI+. 12 �S —�
❑Monitoring 1(]Recovery ft. ft. C�
Injection Well: 30 3 e Idr' ft. ft.
❑Aquifer Recharge aQGfoiirsY3water Remediation �� t.A
rr.V: •-. ✓ io19°SAND/GRAVB 1ZNEIC(ifayplicab1e)••: __-_ �__--_ .�_ y_-_-_`�S+
❑Aquifer Storage and Repoyeryl..;,.,.,•-gri•❑SalinityBarrier FROM TO MATERIAL EMPLACEMENT METHOD .
❑Aquifer Test t�'J �'`` ❑StomiwaterDrainage ft. ft
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer 2tl:DR 11 G-TA G-(atta`e fs`dditiFfilitslieiti.ifnecessary)i.:7 -- "^
❑Geothermal(Close g/Coolin Return) ❑Other(explain under#21 Remarks). FROM TO DESCRIPTION(color,hardness,soil/rock type grain size,etc.)
Date Well Started it- - 2, y 0ft. 76 ft �ir .1 IS Sa„rdy 1:430e Aar}
4.Date Well(s)Completed: I 1.-S -Z77 Well lD#, P 4t 7' -70 ft. e i ft 9 r&^ 4 e ) k
5a.Well Location: Phone#: 3 2 -q /j al ft. I g S it r'e cJ l°v+r--, 6 r ,i;t'4'41
"—ooze et eS' 1 gal . - f,b s ft. 7 96 ft. Sil f4 yyen* R
Facility/Owner Name j Facility ID#(if applicable) !Q(� ft. 2 i ft. r"`v .l j tAN S v, J
C (t rae".I f
333 R l�r// f 5 4s V d Bes L I1 �. e� &"..�, . ft. ft
Physical Address,City,and Zip 1,..) rio lZ' ft. ft
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) / 22 •Certification: e, r J• //�
3 2O2AdC N �®a a- & q6 - W , v F AAA �'^ , s !•'1)
6.Is(are)the well(s): rmanent or ❑Temporary y .atone of Cr- fled Well Contractor • Date
9 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 L�'I o ISANCAC 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 remarks 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 constmction 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: f_ 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 2,4 0 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-30a 200'and 2Q100')
10.Static water level below tap of casing: 50 (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If wafer level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
• 11.Borehole diameter: C (in.)Bit Off: K.L Z 24b.For Injection Wells: Copy to DWR,Underground Injection Control(I(IC)
(f Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: a 1 r. go tG-t y/ 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
- (Le.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 C"
(gpm) 3 O Permit Program,1611 MSC,Raleigh,NC 27699-1611 Z
13a.Yield Method of test: QL%"
70% hth - Date Site Visited: (o"( 111-' `:
p
. 13b.Disinfection type: Amount: i 2 Oz Site Visited By: 0 S
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Form GW-1 -North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6 2018 �'
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