GW1--02340_Well Construction - GW1_20240410

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contract° L
Informa�tjion:
144 L. Gwvt RIRWA'TEVZONES:: ::.:• sR
FROM TO v DESCRIPTION d
Well Contractor Name
(1 amee� �C-t. I P✓ft /'�
35-/"[ — JJ ft ft r 3
NC Well Contractor Certification Number ;:15:'0I R::Ce1SING'(feremulti"cased:'vielICORLI1,VEL ireip`1idili of :::."... ..
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS 1 MATERIAL Cr.ft, ft in.
-
Company Name (�
1 a16IlVPTI�.R;CASIING.O12 TOMN.G(gedthe'[mal`el o"s@Tlo°p7• .. •....•.:*•..•, .•';: _ .
2.Well Construction Permit#: FROM TO DIAMETER TSICm' SS MATLRTAL
List all applicable well construction permits(ie.UIC,County,State,Variance,etc.) + 1 ft ?it ft U i�, . 11I rc,.. S..1-G`( ft
3.Well Use(check well use): ft. ft a in. S
Water Supply Well: ;::17 SCI F:E 1:..:.: 9.: :". i‘' ';_:....._"._,.:.= ::_...:";.;:.; ":`:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) :'r195GRODT
❑ISigation [Wells>100,000 GPD PROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft e2 5'ft .'3ei1tn Ik 0, ,L40ar o,
❑Monitoring DRecovery f. ft. f
Injection Well: �� ���
ft. ft
❑Aquifer Recharge oGroundwaterRemediation r y._
❑Aquifer Storage and Recovery O&M.,ity Barrierl r19.SAKI)/GB iMita ACKfsi bye),.,ii:1: .. ;;:::-.:' ':':i_-:::: ::�•::
PROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ['Subsidence Control ft ft
0 Geothermal(Closed Loop) ['Tracer 20:DRI1 INGIOG,(itfiiclindditioua1eheeti'ifnecessary) • - -
FROM I TO I DESCRIPTION(color,hardness,soWrock type,grain size,etc_)_
['Geothermal aleating/C olio Return ❑Other(explain under#21Remarks) ft. , /
Date Well Started - 3 �a f� �Q�/� /�y[j ® 3 t ft. .S gf f, /OL ass
4.Date Well(s)Completed: 3-14,•4 Weem#1114.-®V L 1 ' 3t.. ft. 3g V o0Q CatV--eirA
Sa.Well Location: r. Phone#: a ' - 67043` ft. 6� ft. Sr#t'i I Pr G'C t!.f / /`I U at
Gain rrG lie) .erns Cc—ft. SGa- ft M l gra7 ati;�c
Facility/OwnerName Facility lD#tdapplicable) ft ft i ;--• '
p' AI (� pp �7r pt s i
t'ttdile,ft Va.'ky Rt� cfal®�IFVef, 84/57 ft ft a.r1�...i NI L,.
Physical Address,City,and Zip 1 ft. ft APR 1 0-2 0 24 C
A tie,
1152E1WAVES
County Parcel Identification No. •• .-.- -
ucr,.., ..,•47
Sb.Latitude and Iongitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) t 22.Certification: ...C.3 f © Ls to" N 16° :31 x&'f w
g -1 ti -.21
6.Is(are)the well(s): ermanent or ❑Temporary Signature of ed Well Contractor Date
'
By signing this farm,'hereby cernh that the wells)was(were)constructed in accordance with p
7.Is this a repair to an existing well: ❑'Yes or *To 1SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy p'
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. k
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. CM •
drilled: t 24.SUBMITTAL INSTRUCTIONS ra
9.Total le w depth below land serer: e: 07 (ft.) Submit this GW-1 within 30 days of well completion per the followings
For multiple wells list all depths if d different(example-3Q200'and 2@100)
10.Static water level below top" E V of casing: 24a. For All Wells: Original form to Division of Water Resources (DWR), �A
If water IeveI is above casing,use" " . (f t) formation Processing Unit,1617 MSC,Raleigh,NC 27699-1617 T
11.Borehole diameter: 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Crn')glf-B Off: �' Program,1636 MSC,Raleigh,Ice 27699-1636
12.Well construction method: at I,/' re,7A 7 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(s.c.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
13a.Yield(gpm) ( Method of test: /'/. v Permit Program,1611 MSC,Raleigh,NC 27699-1611 a o . Q e fr
Date Site Visited: ,'q /ay.
. 13b.Disinfection type: 7��° hth Amount: J Q OZ Site Visited By:
' L4t .
Form -1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
Price: