GW1--01736_Well Construction - GW1_20240315

/J'?WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contra. tor Information:
L n E �� 04:wATE2i`ZONES
Well Contractor Name FROM fTO°°�� ft.
DESCRIPTION
43S tree -A- �S 3-ft.ft - t '/�
ft
' NC Well Contractor Certification Number :15.OUTER CA SING(fer•'multi=cased'wells)OR I '(if`•gg hirable): _-'______ _
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS 1 MATERIAL
3 ft rig ft. J O 11 in. P v�
Company Name ---- ---
'16.II�IEIt' GORTQBING:(geothermal elosed468.p)N:7:;_ _. _ 1
2.Well Construction Permit#: Li 0 3 7 a PROM TO DIAMETER THICKNESS MATERIAL S
Lint all applicable well construction permits(Le UIC,County,State Variance,etc.) 4-J ft. 124 ft. et 2sm In. 112 D .'C i ( ,nn/1
3.Wei Use(check well use): 1 ft. ft. in.
Water Supply Well: - --...\ FROM ^ TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft, ft. in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) _18 mew. . - - - - -- --_-'
❑Irrigation ❑Wells>100,000 GPD FROM TO MA EMPLACEMENT METHOD&AMOUNT 1r/t'
Non-Water Supply Well: 0 ft. 124 ft Pt✓� PEtfi wry._ era kh� t v S
❑Monitoring ❑Recovery ft. ft. !7'1 fi/_uJiaS
Injection Well: ft. ft
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DAquifer Recharge .0 Groundwater Remediation
F 19.SAND/GRAMPACK-Cdapplicable)': _-_- , ,
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENTMETIT OD -
❑Aquifer Test ❑Stormwater Drainage ft• ft.
❑Experimental Technology 0 Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20'iDRTEZING'1;OG'(attach-additlbnalsheetiffnecessity) .___ -1- - IT -_
OGeothermal(Heating/CoolinoReturn) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardaess,sell/rock type,grain size,etc.)
Date Well Started `;C- )- -'L1 ^^ PP�� /� / 0 ft. i 11 ft. _'oe'1 f v t c L, &t ut'l kik
4.Date Well(s)Completed: -(q a-f Well II#AA UI�V `3 74 ft. /s ft Fr„, '�1rt, roc. /l4Ja -e e.- 10
5a.Well Location: Phone#:.136- '81?- J701 15-fu 1Offt. 4.a 5'0y
,o ,�!'r'soG4o11g Cf Se,,7 10 c fu :14^ orev . G rob C r C?ti (
Facility/Owner Name Facilitya ID#(if applicable)bl ft o�ld`-ft.
�/e� 4 6 f4ae it. CttuP .f . i'I t l i' y ft ft
Physical Address,City,and Zif Aro &240 ft. ft _ ^ ,_' ,.., -,
County Parcel Identification No.(PIN) IVIHn -
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllongissufficient) 22.Certification: triftwma4icri Pr- ng Unit.
w crni= ,c tV�.dt3 0�r7^" 1 :O
6.Is(are)the well(s): Permanent or ❑Temporary Signature of Certified Well Contractor Date 1i
By signing this form,I hereby certify that the weIl(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or Illitto 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
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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. CP
23.Site diagram or additional well details:
8.For GeoprobelDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
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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. 5
drilled: 1 �,j i 24.SUBMITTAL INSTRUCTIONS
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 ifd jerent(example-3@200'and 2@ 0)
10.Static water level below top of casing: 324a. For All Wells: Original form to Division of Water Resources (DWR),
0'0 Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
G 7 0 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC) 1,9
11.Borehole diameter: On.)Bit Off: �4 Program,1636 MSC,Raleigh,NC 27699-1636 ,C''
12.Well construction method: d3 i I ('0 fq 17 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the 0
(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
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:. (� �l�
o - t Date Site Visited: /0 ! -C 3
70/o hth -i/ OZ Site Visited
13b.Disinfection type: Amount: By: A'►,4
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Form GW-I _ North Carolina Department of Environmental Quality-Division of Water Resources ' Revised 6-6-2018
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