GW1--01679_Well Construction - GW1_20240315

„,..:;WELL LY..CONSTRUCTION RECORD (GW-1) For Internal Use Only:
..rl'.Well Contractor Information:y
7. t C rm41 4 WATE11:LZONFS':.-HM:is>�•: •t!1:::<'._,:f$."2',1: K•'-'i la i':L:a'_._..4`,.,t
Well Contractor a FROM TO DESCRIPTION
7 VI)4 ” qf ft. 9& ft. t . I Pixeitureof
it ft
• NC Well Contractor CutificationNumber u15-OD171rCA:S NG(focimulfi=eased ells)ORIINERAif ap'lic"able).�.`-: z,; '==-1,
Yadkin Well Company, Inc. _ FROM TO .DIAMETER. THICKNESS ' MATERIAL
ft. ft. !' lin.
Company Name ,___ ,_-•, _.,-,
B��,p !ii:CTINEItCASING,OR.TQBING:(ge'otberousl:ddsid;1611 % �.�._:Inr.i5...l.
2.Well Construction Permit#: 4• 0 7- M J FROM TO DIAMETER!. _ THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) .14• ft. 39 ft.
40-5 in. -r4a/G�¢9 e .
3.Well Use(check well use): ft ft !in.
Water Supply Well: rI SGAEFS , =1:=— - -_- _- :
FROM TO DIAMETER. !SLOT SIZE— THICKNESS MATERIAL
❑Agricultural �❑/Municipal/Public ft ft
•
OGeothermal(Heating/Cooling Supply) HResidential Water Supply(single) ft ft in '
❑lndustrial/Commercial ❑Residential Water Supply(shared) 1i0.08017L w< ;= :�-_"-: -' —� - -
• v
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL' EMPLACEMENTMETHOD&AMOt1NT
Non-Water Supply Well: 0 ft 5` ft gmeg;`./,g IRS gfeal
❑Monitoring ❑Recovery 3 P t• 27e ft• 4 0',A7 ?ger°,
Injection Well:
ft. ft
❑Aquifer Recharge ❑Groundwater Remediation __�____�__.
❑A uifer Storage and ❑Salim Barrier a91:SA RAVEt'EACIElitiiii licabie)� " " :- •
Q $ Recovery t3 FROM TO MATERIAL' J EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft
❑Experimental Technology 0 Subsidence Control ft. ft. i .
OGeothermal(Closed Loop) ❑Tracer <20 DR11;IIIdGZOG(iittach saditional`slie"ets•ifnecessary)=- -
OGeothermal(Heating/Cooling Return ❑Other(explain under#21 Remarks) FROM TO• ➢ESCRIETION(color,hardness,soil/rock type,grain size,etc.)
Date Well Started ,�a 70.,, ® rt. ft. ®e
1
4:Date WelI(s)Completed: s �4P y Well DO 1 ) f<• .,®�e ft { � i ,;g ,�
Sa Well Location: Phone#:9f9- C2- V032- lg.. ft. 55 ft •.try • ,{ p6�` ita� �/
ft. �� ft, fDM n if
Allen A.7y ice. 4
Facility/OwnerName Facility Il)#(if applicable) glS• ' 3�c t pe earede
ft.
( Ce..�0V . T"Vp)e,i 1 •- arr✓�.,y;•I, - . • • 5- ' ,— . i .I
Physical Address; and Zip ft it .
f
County • Parcel ldentificaiienNo.(PIN)
• L:,-,K, OCR
511:Latitude and Iongitude in degrees/minutes/seconds or decimal degrees: r' .,
(ifwelonelat/longsufficient c• •••-e
• fold, g is ) 22.Certification: I
�� N ��, W 1 l',•</,
, 6.Is(are)the well(s): tlf�ermanent or ❑Temporary Signy ofCe Well Contractor I Date 0
00
-8y signing this form;I tify hereby cer that the• well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes .or fiNo 1SA NCAC 02C:0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is'arepair,fill out known well construction information and explain the nature of the of thisrecord has been provided to the well;owner.
rep air under#21 remarks section`or oh the back of thisfornn• '
23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction info ad
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 OF-1 is needed; Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary. ,
drilled: i 24.SDBMITTAL INSTRUCTIONS
0
9.Total well depth below land surface: ® (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3@200'and 2@100)
® 24a. For All Wells: Original form,to Division of Water Resources (DWR), To
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"+" I
11.Borehole diameter: C (in.)Bit Off: 5+96S. 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
i
12.Well construction method: o�itee./er 24c.For Water Supply and Open-Le op 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
�,., Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) /I? Method of test: C-r °s" , f fit. . C
70% hth �y Date Site Visited:y-4# ); �° efQ vt°�S
type: ° 7 OZ Site Visited By:1D. 3, 1 s«t 1.3 C.:t�,�-�R& -
13b.Disinfection Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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