GW1--03225_Well Construction - GW1_20240528

frELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
.Well Co tractor Inf_zyorma 04:WATER ZONES `
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1:1
Well Cont act rNam ,_FROM TO DES I IPTION
ft
Lf6le S ft. ft r
NC Well Contractor Certification Number 15:OUTER CASING(fiir iliti:eraed'weIls)OR LINER(if-'11ea6le),-! f'("
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNE.SS"1 MATERIAL ^
ft. ft in. PCI-
Company Name
O �f ., '16.INNER CASING OR TUBING(geotliermitl closed ooP)
2.Well Construction Permit#: (4 0i 3 - 2..3 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C County,State,Variance,etc.) fit ft. 33 ft. 19)vi in. SD A-AT PIK)
3.Well Use(check well use): ft. ft. in.
Water Supply Well: ' O DIAMETER I' SLOT SIZE yTHICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft In.
OGeothermal(Heating/Cooling Supply) Silresidential Water Supply(single) ft. ft in.
❑lndustrial/Commercial ❑Residential Water Supply(shared)• :18 GROUT
❑liilgation ❑Wells>100,000 GPD FROM TO MATERIAL. EMPLACEMENT METHOD A AMOUNT
Non-Water Supply Well: 0 ft. 39- ft at>C)�5 9 Cass i'i y il5 8.
OMonitoring ❑Recovery ft. ft.
Injection Well: ft ft.
❑Aquifer Recharge .OGroundwater Remediation
i 19.SAND/GRAVEL PACR'(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL _EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology 0 Subsidence Control ft. ft.
OGeothermal(Closed Loop) ❑Tracer '20.DRIETINGLOG(attach additional sheets if necessary)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Rrmarlrg) FROM TO DESCRIPTION(color,hardness soil/roek type grain size,eta))
Date Well Started H-aa a, 0 ft 17 ft 5Q; ) ,
4.Date Well(s)Completed: I-FA�� Well ID#A-An'�9�k )1 ft /Lialft g etc
Sa Well Location: Phone#: 22.'Z- 717-97'� ft• ft. yl-
'I- s,.. C a
L. da �v�ox(e� ft. ft.
MAY S �G24.,
Facility/ er Name Facility ID#(if applicable) ft ft
zaiq.r Lo -/aw.1 P (°°Ho ill e-i 1JC2.11)° ft. ft..
. ' . _.
Physical Address,City,and Zip ft. ft _
Kt \ -i r\ 21.RENrARKKr .,dYS' . .:. `a,:' XIV `L..r, 44'-;^;'..*4 'ii:rz.Aa-1:
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.
e/todY
Certification: U
3 k,, Zrj 17���s N et)a 17(C 9_3,2 W O -05 14PI J6.Is(are)the well(s): QPermanent or ❑Temporary Srgaature oftified Well Contractor Date
``'' By signing this form,Thereby certs;fy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or ltlNo ISA NCAC 02C.0100 or RSA NCAC 02C.0200 Well Construction Standards and that a copy r?
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. j-
repair under#11 remarks section or on the back of this form. C
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: 24.SUBMITTAL INSTRUCTIONS (p
9.Total well depth below land surface: r q9, (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3(4)200'and 2Qa 100') P.
9yZ- (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"+" p 4 •
11.Borehole diameter: (in.)Bit Off: 5� C!• 13 24b.For Injection Wells:Copy to DWR,Underground Injection Control(Inc)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: A h--- 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
To
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
Aft-' Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) O Method of test: 2 3 A/u S ht.o Date Site Visited: II -L&-
13b.Disinfection type: 70�O hth Amount: V OZ Site Visited By: pT/3
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018