GW1--01692_Well Construction - GW1_20240315

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I:ri'�G1 CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: , , K•
0 d 6A) i 'I i A �1 ( I\ �I1 ' �� .i4:;Wi1TER7.oNEvin-,.. ax"'.'.�S ✓ ;=t1"}6...::u-�r-sq...,.ram ,-'o;,f- •/
�yJ • .FROM TO DESCRIPTION
Well Contactor Nam( ft. .L.' ft' L N -
6bm- is
ft. ft
NC Well Contractor Certification Number
t15LOUTER`Gi1SING•(f6i'mulli=cssed3veIlv):ORL]NF.I2"(iL'a"licalile)q,-2Pi•-��'t< ,
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS 1
end
rf ) ft (0 5 ft (..I4-S';ln. 5pi_11 v(
Company Name g 6�q ;�ISCIN CS, ING:OR:UBING(geotlieiaiarelaedloop)'.�'i . :2..i
2,Well Construction Permit#: paIlf�IiCI 2o .Z ,._Z g Cc/ FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Comity,State,Variance,eta) ft. ft in.
it it
3.Well Use(check well use): , in•
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
l7Agnoultural ❑M��lmicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) esrdential Water Supply(single) ft ft in, ;
❑Industrial/Commercial ❑Residential Water Supply(Shared) ::18.GRbUT> - '---- .�_ _ ; _---------,1
❑Irrigation ❑Wells?100,000 GPD FROM TO MATERIAL I EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 6 ft tu% ft .w,16,,i'7It. ej,,la ti e z ur
❑Monitoring DRecovery ft. ft. • •
• Injection Well: - ft. ft ' '
❑Aquifer Recharge ❑Groundwater Remediation _-.__� __ _-
i 19rSMW/GRAVEL`�PAC Cif irliplicable)':.:�-
oAquifór Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL, EMPLACEMENT METHOD ~-•
❑Aquifer Test ❑Stormwater Drainage ft ft 1 •
-
❑Experimental Technology ❑Subsidence Control ft. ft
El Geothermal(Closed Loop) ❑Tracer gi10✓D11.1T iNGTiOG7(attachaailidoriiil"slieet"s:ti'necessary)=_=__.____- •
PROM TO DESCRIPTION(color,hardness,soil/reek type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21.Remarks)
_ Date Well Started '-7 2s$ -1 '\ . 0 ft 05 ftSU p),J ? ir .
v
j
4.Date Well(s)Completed:l 0 L 0-/�� Well D#A/C4�� /y
"9,V2- PL. j ft '0 J ft �1D: /�
5a Well Location: Phone#:WIC-.7®r�.724q t i ft C3o® ft M ;��tr• (CPI- .
p� t ft ft, L/
'`ileum Up-I t Ct(, _
Facility/Owner Nano' Facility (ifapplicable) ft ft I. r. -t.z-- o i' ti
lD# a licable ' .f L..o .i.`
/fl fL ft t�
�'' 1043 MAR .1 1024"
PhysicalAddmss,Clty,andZip ft ft
i2ferRE1cria tC __.�.+, __1 -„a_..i.-�2' .may_ -.'.
County Parcel ldentificalionNo.(PIN) til'A::i"'-'.�•`•
5b.Latitude and Iongitude in degrees/minutes/seconds or decimal degrees: .r
(if well field,one lat/long is sufficient)
22. tifcation: '
�
4
3G. ) I3�3 N ®, �� w UF! • It ', s 7_
1 of C" • Well Contractor ' Date
6.Is(are)•the well(s): C 'ermanent or ❑Temporary 1, ,
By signing this rm,'hereby cert fy that the wells)was(were)constructedin accordance with ,�a
7.Is this a repair to an existing well: DYes or nlie. ISA NCAC 02 .0100 or 15A NCAC 02C 10200 Well Construction Standards and thdt a copy
Ifthis 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. • �o
repair under#21 remarks section or on the back ofrhisfarm. 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 construction info -CA
(add See Over'in Remarks Box).You may also attach additional pages if necessary.
construction,only 1?W-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 24.SUBMITTAL INSTRUCTIONS C>
9.Total well depth below land surface: g 0 6 (R) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3©200'and 2@100) i i
` 24a. For All Wells: Original forth to Division of Water Resources (DWR),
10.Static water Ievel below top of casing: (ft•) Information Processing Unit 1617:MSC,Raleigh,NC 27699-1617I.
If water level is above casing,use"+"
j{3/' 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.)Blt off: l Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 1 .a P 9-c)` '�li 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the uo
(ie.auger,rotary,cable,direct push,etc.) county environmental health departuient of the county where installed
I ,
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
�Q ` Permit Program,1611 MSC,Raleigh;NC 27699-1611
13a.Yield(gpm) 1 Method of test: '" - � '^J p�v s
70% hth G t oz Date Site Visited: fo/6-'XX
. 13b.Disinfection type: Amount: Site Visited By: ®%I
•
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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