GW1--00769_Well Construction - GW1_20240131

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- WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: '
_ I
1.Well Contrac r formation:
/A��l ! �d✓0 �' �,V� 4 WATT:R•ZONE,„„:,? -'_. ..„.. ,al;':'4:2t e,ir_�;,__ .; _ ,..,
.S FROM TO . �� DESCRIPTION
We1l Contractor Name i 3 ft I75 ft
3s-tt ? .A J ft ft . !
NC Well Contractor Certification Number „15:;OUTER'CASING'(O multias-eldweDs):ORLDIER X.El 'llc'able)•1=-.1:'�
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS IVIATERraL
ft ft. in.
Company Name
`c16:I INER'CASING:OR:T OBING:(ge'o'ther ifire osid iiiiii'3' =7-71. 5: v:,71s
2.Well Construction Permit#: 70 �.5 (0 FROM TO DIAMETER THICKNESS MATERIAL
List ail applicable well construction permits(i.e.UIC,Comity,State,Variance,etc.) . I ft, 1 r1 6 ft 6 t j•�c in- f j�R r • P l (
3.Well Use(check well argaltattinff use):
ft. �C ft L in. V V l • !i (�
Water Supply Well: - ----�__�,
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic ft _ in. �,� - `
❑Geothermal(Heating/Cooling Supply) Vesidential Water Supply(single) ft_____.---ft, m
❑Industrial/Commercial DResidential Water Supply(shared) •'.:18.GROUTfiL�- ...-_`—-- - ----" --`-- _—'.---.--_-__•• .
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL w EMPLACKMENTMETHOD&AMO
Non-Water Supply Well: 0 ft' .�'14 ft. (fYn-lan j 1f Ci t (•U0t r
DMonitoring DRecovery ft. -1 ft �lI qs
Injection Well: ' J
ft. ft.
DAquifer Recharge ❑Groundwater Remediation i _
_'19 SAND/GRAVEL PACK-(if npplicable)';.-�''.,':: �i�;. __�_ ,
DAquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD '
DAquifer Test ❑Stormwater Drainage Fr.-
DExperimental Technology OSubsidence Control ft'— t.
❑Geothermal(Closed Loop) ❑Tracer i_r20tDRa.ING1:OG(atEacli aitdli onil"slieets`1f:necei.iliy)` '-.. ;
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,(lain size etc.)
Date Well Started // t I 0 ft. ft Jul f
4.Date Well(s)Completed: 1)-)2 23 Well ID#,j0`/4f f rJ 9.,. ft. �1 Li ft r t F L. GJ«7 SU�'� I P�4
5a.Well Location: Phone#:$2w- 99°-/'-27J ;if ft. 1(5 ft. �u r I ; J., s'rl i i ; - -
ft. l A. ft.
aciltty/Owner Name Facility ID#(if applicable) ft ft =.i ,:/ r;,-,-..,
ftlA •
ft. ft _-r, u- ?` a
Physical Address,City,and Zip' ft. ft JQI�� '-,. �G24
'`9 pit u21 REMARKSra•.:7.-F,= ....... `:_., i'i' e
County .� .Parcel Identification '" •,'•>�' ,•
�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ,- ---
(if well field,one lat/long is sufficient) 22.Certifieatio
i
. 36 ' /% ' Ll?" N F!P" 110 3t" W
C - . - I)' a2—€2
•
6.Is(are)the well(s):'ermanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,Thereby cert fy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or XVo ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form. • . _ ' . , •
: ;.•, 23.Site diagram or additional well details:
8.For Getiprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info -
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells , (add'See Over'in Remarks Box).You may also attach additional pages if necessary. '
drilled: '•
G \ 24.SUBMITTAL INSTRUCTIONS
9.TotaI well depth below land surface: I (ft) Submit this GW-1 within 30 daysof wellcompletionthe following:
For multiple wells lint all depths if different(example-3Qa 200'and 2Q100')--. - • per
4 s\' 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: -(fh) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+' -
II.Borehole diameter: (in.)$It Off: 6 a Io •' 24b.For Injection Wells:Copy to:DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC27699-1636
t -11 .
12.Well construction method: 4/I rp 7'el s' 24c.For Water Supply and Operi-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) ' .�
-coun• ty 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
, Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a Yield.(gpm) Method of test: Ci n t !
o Date Site Visited:IL- i "r 2 J
13b.Disinfection type: 7O�o hth Amount: OZ Site Visited By: '/t4}/
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
Price: ,