GW1--01670_Well Construction - GW1_20240313

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.' ‘..,.. .Y.. WELL.CONSTRUCTION RECORD (GW-1' For Internal Use Only:
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', • 1.Well Contractor Information - . ' .::;- i
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FROM TO. .•' DESCRIPTION
.f, • Well ContraCioi-iqame f• ' ' ' , :'', :..;. .
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NC Well ContMetor Certification Number- f15'.01:FIER'.6..XSING.(fiiiiiiilti;:diiildNielECORLINEICtifainfailire5r-:-=:,7-VA---,
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL 44•
ft. ft. 1 in.
• Company Name
1.6rIN.NRICGASING:ORIDEDIG:Xtelitlieliiiiireliiiingi3):7;:r
- .2.Well Construction Permit#: .3 76 c.,,s- FROM . TO - .. DIAMETER THICKNESS MATERIAL =
List all applicable well construction permits(i.e.U1C,Count",State,Variance,eta) ,A..
3.Well Use(check well use):
Water Supply Well . .
,. .FgeftElfoir_.:::•,...),-..37.-'7',-.=----_ =_=:_:.___-:-...._17..=..7.-7.1 0
FROM TO DIAMETERS SLOT SIZE THICKNESS MATERIAL
OAgiculttual • OMunicipal/Pnialic ft. it. - in. . . .;
OGeothemial.gleating/Cooling Supply) ' residential Water Supply(single) - ' ft. It. in. 0
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Olndustrial/Commercial °Residential Water (shared) 118':OR01.3TC------=7---.7_-.....T.=.7..:--L------.7--.___----..f.7.:_7:7-..,
OIrrigation ..^... OWells>100,000 GPD:,:'..... ' FROM TO ' MATERIAL • IINTLACEMENT METHOD&AMOUNT '1;mo•
Non-Water Supply Well: ..P . , 'f , - .0 ft. ft.
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OMonitoring• .• . .,' ORecovery , , -. ft. ft • •
Injection Well: -.
. ft. ..p ft. .
DAquifer Recharge .p Groundwater Remediation
f7.-3.9YS'AND'/GRANIMPACIC(ifarriilielibler= --_--2.7.7.:,::--72"....:=2...:2:. .....,
OAquifer Storage and Recovery OSslinityBarrie'r FROM TO MATERIAL , EMPLACEMENT METHOD '.-
Okjuifer Test ., OStormwater.Drainage It. ft. ,
OExperimental Technology OSubsidence Control ft. , ft. '
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••••• ":•,.. . I:Geothermal(Closed Loop) OTracer 1.10.1TRIEINGTOG'(iittiWiiddittiii'elriliatilfilees-Ta-.4)====7_7::= I_
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TO DESCRIPTION(color,hardness,soWro dr tYpa,'grain size,etc-) •
s :' • OGeoth al aleatini/COoling Return) 0 Other(eiplain under 4'21 Rerharlcs) FROM
.i. • 1. .Dptp,Well Started ,i 1311:4 ..; t 1 e YolL. 41/W .•
4.Dic. i4(s)Conpleted ). 2 - Wlli#M10 j)2l ft. • ft r7.7 .---,,,7
Phone#:33 ii....-' i-fia/ AHso ,. ft. ft. E'10,-........e L....f. V
5a.Well LoCatioti:' ':•'';'1''
ACLM . AS .'t.'e,41.i( 411M ''-....C10.t.,. ku.,.±,; cf; ,Ce,,;i,i+ f• t. .,'. ft. MAR i .S 2074 ... ., •.,
•. . ,.Facility/per Name.. " , ', Facility„. (if applicable)
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I - • 1 ft. •• ' ft '.ArtfdiTreten r'rr;:::14..=1;2,t..:P.). • ; „ • :,-:-„'
'.1....i„,,S7 3 c,":'-,::':'-Alj., give"' Oiu i.tik, • • W ts 4- n. e:41,tcsa, „ ..
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ft
,PhySic:elAddllesCit,and Zip ''.,,21 Lci 9 . ....,
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Cat REMAIMS K=.7_:::::::::::.:".1.::::=7=2..r.:--".","="---..= ' '• '-L i
. ''..-- -. ,- ......,.: . .... -02. - , /631149n. 17*
Parcel Identification No.(PIN) g + 6 : 66-S-" bits • 44 tx,r8,7.
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,..c. , 51).Latitude and longitude in degrees/minutes/seconds or decimal degrees:
[:.,.'. ..--•- (if well pe14,onelritilong is sufficient) 22.Certification: • . . . '..v';:: ':;..',- . . '.i
.s4• :.;n1.4:;:„.g.1 'i.11 N 2-16 OLJ 3i5-17 "f.
6 v_s_m..-.' • .Go-,,A5r,,,.:-. -,:; '- " 1,-,..
6 Is(are)the well(s) OPermanent or OTemporary Signature t f cartifitd Weil Contractor ,, ' -i '',,I,'; -,i a:Date
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rA II D, .....:: signing Mil form,"hereby cerd,that the well(s)was(were)Colis'iru ctedin accordance with
7.4 this a repair to an existing well: )4(es or t9No,vri% 1 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
• . Ijihi.i is a rePair,fill out known well construction information and explain the nature of the of this record has MenProvIded to the well owner. . ,
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repair under#21 remark section or on the back of this form. .
23.Site diagramor additional well details: 1.--.;"---
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the backrof this page•te provide additional ell 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 if necessary:, -4----.'`''
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drilled: \ . 24.SUBMITTAL INSTRUCTIONS- „., ,,. ..., ,, . .. ' '.. ..I'
9.Total well depth below land surface: 710 • ,(ft
--- GW-1 within 30 days:of well completion i . - .
For multiple wells list all depths if different(example-3©200'and 2(gl 00') , Submit this - , tion per tiie iolloWngi-,
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1.0.Static water level below top of casing: (ft.) 24a. For AllWells: Original form to Division of Water Resources (DWR),;
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: C (in.)Bit Off: .5-15410 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,Ng 27699-1636 . '-',-..)
12.Well construction method: AI I re).67 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 producing over 100,000 GPD: Copy to DWR,CCPCUA -0
13a.Yield(gpm) Method of test: ri Alf- Permit Program,1611 MSC,Raleigh,NC 27699-1611
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70% hth 3/4 oz Date Site Visited: 1.)
. 13b.Disinfection type: Amount: Site Visited By:
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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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