GW1--02296_Well Construction - GW1_20240410

LL CONSTRUCTION RECORD(GW-1L For Internal Use Only:
1.Well Contractor Information:io ��/�ply j�
��Y rNa `J ICl/jVW[JY V 14:WATEB•ZONES=_-. ....C�.--.;'.`- -- -_--1: ,_..._...-- -_ - �+E
f FROM TO • DESCRIPTION p� 71Di'
Well Contractor Name • ft t, J n e,(6 Amon JI 11 Cp�
ys4 �z�
it ft
NC Well Contractor Certification Number 15:'OIITER::CASING'(fd?:multi=cased:wells):OR'1;INER.(ifap•licatile)i_:___... p
Yadkin Well Company, Inc. FROM TO DIAMETER TEDCE ESS MATERIAL sq
ft. ft In.
CompanyName ';.16INNERCA5ING:ORTABING(geitlierinalelokinob --
LA) I. 2...07 PL
2.Well Construction Permit#: S 1 F 0` go(— a S FROM TO • _ DIAMETER THICKNESS I
List all applicable well construction permits(I.e.UIC,Canny,State,Variance,eta) �.1 ft IRS ft ]n at in. 6d/ Z
ft. ft v in.
3.Well Use(check well use):
Water Supply Well: FROM.FROMRPIA. DI - __ - - - -
TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑M�unicipa]Public ft ft. in.
❑Geothermal(Pleating/Cooling Supply) C5esidential Water Supply(single) it 1. in-
❑Indestria)/Commercial ❑Residential Water Supply(shared)
18i' MOM .. ---- -- --- - - - - ----....
•
❑laigation ❑Wells>100,000 GPD FROM TO /� A_MATERIALG EMPLACEMENT METHOD&AMOLUUN'I p
Non-Water Supply Well: 0 ft. s i f t i P P NI Ito Oaf!`9 r
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft. _
❑AquiferRechazge ❑Groundwater Remediation i 19.SANDIGR'AVEli•P.ACIC(if`appliaible)' ___. _.__ _ _ .
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test ❑Stormwater Drainage ft. ft 'n
❑Experimental Technology OSubsidence Control ft. ft. •VI'
❑Geothermal(Closed Loop) ❑Tracer 20.DRIMINGLOG(attach additional-sleets if necessary) _ __
FROM TO DESCRIPTION(color,hardness,soil/rock type,Brain size,etc.)
❑Geothermal(Heating/CoolingRetum ❑Other(explain under#21 Remarks)
0 ft ft .+ �y _
Date Well Started : -u1/4-.VA A � s i
4.Date Well(s)Completed: 2 4 "t Well ID#Ada' %44 ,S3 ft 124 ft. [gkyw, 0.1±44
Phone#: .33 Vie-3s$12- l eO' ft, e . ,ft /�,C�d • % lY j '�'1134 ;l�f 1/VVVV
Sa Well Location: v 'p4 � I9cq..t7egv �g g, _
Fa ility/Owner Name Facility ID#(if applicable) ft ft.
51g2-) S;44,•? al F.—Jr6 ei,iipc ..wq' ft ft. APR 1 0 Z024 -
Physical ddress City,and Zip
tth c k i v 2fItEl 'A'RES. - -- -_ - - -- -.i I A A.,.,- -- ' ..`--_- __. _...- - - - --
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.Certification:
- 3(z.- 2 7 0 ll 3` N t O„ G ®fig fl'' w 7 J'
IIYErmanent or ❑Ten or nature o edified Well Contractor Date
wry
6.Is(are)the well(s): p
By signing this form,I hereby certiify that the well(s)was(were)constructed in accordance with �j
7.Is this a repair to an existing well: ❑Yes or au,r 1SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy (4
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. 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
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.
drilled: 1 24.SUBMITTAL INSTRUCTIONS 0),
9.Total well depth below land surface: 9%—?a (ft') Submit this GW-1 within 30 days of well completion per the fallowing:
Far multiple wells list all depths if different(example-3©200'and 2Q100')
�l.' (ft.) 24a' For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: 6. (in.)Blt Off: 10't)V1 24b•For Injection'Wells:Copy to DWR,Underground Injection Control(IUC) U
Program, MSC,Raleigh,NC 27699-1636
12.Well construr�tion method: 6 I V i o tun 1 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 ft
FOR WATER SUPPLY'WELLS ONLY: • 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
0
11
Mr' Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) I Method of test:
o Date Site Visited: V2-y-23 �, '
type:
13b.Disinfection 70�c hth Amount: U OZ Site Visited By: a S3
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018