GW1--02292_Well Construction - GW1_20240410

•
1,CONSTRUCTION RECORD(GW-1) For Internal Use Only: I 0
1.Well Contractor Information: �'
OJ ® d 1 f i I f i6� (v1 1'111C •�/ l{14•WATF :ZONES•='; 1:1,lxil,-. 1.1"�:_ii �. vs
;:: i:::u"....%'!:1,-,
Weil ContractorN a FROM TO DESCRIPTION
I y i 6 a ft. 1 6•6 ft ,S i
6 I -. � ,
NC Well Contractor Certification Number ;3®" ;43 5 f t S ems.
15:O11TERVAS1NG'(fu"rmultr s"gd;iv"eIISIOR'LINER(if:ap licaliler—='_'i_.: r
Yadkin Well Company, Inc. FROM TO D ER TRIMNESS
Company Name i ft. Q S ft 6.1Z 5 in. :5 ,,...Z I 7911e..11_ -i
• p y C. v '.316:INNER CASING:OR.TUBING:'(i eottiermal:closed=losp) -.:'=li^.0
2.Well Construction Permit*: 0 I �1 2 y-/- 2—a `� FROM TO . -- DIAMETER '• THICKNESS MATERIAL
List all applicable well construction permits�.e.UIC, ounty,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft ft in,. .
riggaREZI Water Supply well: FROM TO� �• DIAMETER' SLOT SIZE -THICKNESS y MATERIAL•
❑Agricultural ❑Municipal/Public ft ft. .In. - -
❑Geothermal(lleating/Cooling Supply) desidential Water Supply(single) it. ft. in.
❑IndustrialVCommercial ❑Residential Water Supply(shared) :18sGROUT;r�"-:'_:.1 ----. -_; --_^. -_ �. --i. -
❑lnigation: ❑Wells>100,000 GPD FROM TO RIAL II1�LACEMENT METHOD&AMODNT
Non-Water Supply Well: 0 ft 26 ft I€-f G C)" aikr,) I?
❑Monitoring ❑Recovery ft. ft •. l
Injection Well: ' ft. ft .
❑Aquifer Recharge .❑GroundwaterRemediation _ __•_ _
i?19 SAND/GR'AVFL'PACIC'(if iPPlicalile),.-_ _:.:�.�_ --""'.--- . .
DAquifer Storage and Recovery ❑Salinity Barrier FROM TO ' 'MATERIAL'-.' EMPLACEMENTMETHOD. .
❑Aquifer Test ❑StoratwaterDrainage- ft. ft. . -? ''
❑Experimental Technology • OSubsidence Control" ft. ft ' . _
,❑Geothennal"(ClosedLoop) ❑Tracer :20:DRIFTSGZOG'(iittechaddifion'sil'SL'e`etstinecessary)4 v"'_`-_ •. '; ''
FROM TO..- DES ON(co ,hardness,sail/rocii.type,•grail!dirt iic7•71 ;..--_.
OGeothe�al(Heating/Cooling Retuq) 0 Other(explain under#21 Remarks) : k.
',Date Well Started 3—i i�ti /^� �y ft ft. . •, ;.is y,�;i.
`r4:I)�ateWell(s)Completed:3"!S 41-4 Well ID#AAcaoVI ,.i ft. I(.`'� .It'. 1,\U4L - rAPR:`1 '�1•20241
Sa Well Location: Phone#:70 ' C 252 '9YJ2 6 9 ft (/Q 5 _ft g(Q .t�➢ -
al-ilk # 8 6f ft. I 1 ft. at +ti fr;: ' ,fV' ' f'
IvIc4 ID
Facility/OwnerName Facility ID#(if applicable) )Go R' 10 ft S. icir ,,
..
•
}}` 4.3 /-/00 �o,7 vd / 140 (�° l 41 ft. ')3® ft. 1 ...q :.e¢ v . • .. "
Physical Address,City, d Zip �.•.', 3 30 ". 11$ ft . ®' .! ' e,t
County - Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds,or decimal degrees: •
(if well field,one lat/long is sufficient) 22• • a catio,.i•
e� f� p s L �/
3�.61I5600 N ��0a 8�1 I3li'�� w . 6i-1 >�Z. . ,
Si• o•r:,ed Well Contractor Date
6.Ts(are)the weIl(s): k3)lermanent or ❑Temporary -
By igning t itsform,'herely certify that the well(s)was(were).constructed in accordance with' 7 .
7:Is this a repair to an existing well: ❑Yes or elNo' 15A NCAC 02C.OI00,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 beenproaided to the well owner '.
repair under#21 remark section or on the back of this form. 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
Orzi
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. .13
drilled:_ (�/ 24.SUBMITTAL_INSTRUCTIONS •
9.Total well depth below land surface: 3 l /2 (ft.) t ` ' .
For multiple wells list all depths if different(erample-3Q2000''and 2@100o Submit this GW-1 within 30 days'of well completion per the following:
�}0 •
(ft •24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: ) Information Probessing Unit,1.617 MSC,Raleigh;NC 27699-1617
If water level is above casing use'+"p, • /� _
6 - G 24b.For Injection'Wells':Copy to'DWR,Underground Injection Control(IUC) SU
11.Borehole diameter: (in.)BI Off: Program, MSc;Raleigh,NC 27699-1636
12.Well construction method: a,•
1" 4-Ciiry 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the 9)
(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 11)
(i Pt.. Permit Program,1611 MSC,Raleigh,NC 27699-1611 ` .
13a.Yield(gpm) - _ C Method of test: ��
-•.70/ hth oZ Date Site Visited: I c° Site Visited By: I
13b.Disinfection type:' Amount: � d
Form GW-1 North Carolina Department ofllnviromnental Quality-Division of Water Resources' Revised 6-6-2018
_ -I- - .