GW1--03227_Well Construction - GW1_20240528

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
U1fi,�tX �,, is 1...4
„.14.WATE$•ZONES s l:'i
Well Contractor Name
FROM TO DESCRIPTION
3� 90
ft. 7,2_ ft.
ft ft
NC Well Contractor Certification Number
`;"15."OUTiat,-6i-SING•(foi'multi-eased•WeIL+S:ORLINERGrip licitilef:'
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS �I MATATERIAL
-- /1. /sin. / f�
Company Name
/�
�y si;16FINNER:CASING:OR,ruBING(gedtliesmal daied-4 N' . •
2.Well Construction Permit#: el(�1 q 1 3 "2 ®2-4 FROM TO DIAMETER THICKNESS MATERIAL List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) -Y 1 ft. / 3 ft 6 1/1/ in- SOX- A�l P C
3.Well Use(check well use): ft. 1g it n•
W ter Su 1 Well: z.17::S.c REi .- .. •, .
PP Y FROM TO DIAMETER SLOT SITE THICKNESS MATERIAL
WI
❑Municipal/Public ft. ft in.
m Supply(single)
❑Geotheral(Heating/Cooling Supply) iesidential Water Su 1 X. in.
OlndushialCommercial ❑Residential Water Supply(shared) -,'18'"•GRoDT:: . , . , . ..
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. L' ft.
❑Monitoring - ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation r _, ,,.
I'.19.SAND-/GRiMI ..1CK(ff.apphctib`Ie)1
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD '
❑Aquifer Test ❑Stormwater Drainage t• t e
❑Experimental Technology ❑Subsidence Control ft. 7t /
❑Geothermal(Closed Loop) ❑Tracer 20:D=11NG- OG(attachidditional•sheetiifnecessary)';:;'-;•.:•C:,.:':... '..,.
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) FROM TO DESCRIETION(rotor,hardness,so111rsek type grain size eta)
Date Well Started 2- 2$i / o ft �� ft. •,�© f f
4.Date Well(s)Completed: sr'2-Z�/ Well ID# la/ j 'ft 'L ft 6r f.., - -.T
Sa.Well Location: Phone#: 336 -%) - /Q‘74 ft. ft
ft.
R6 n 86 L I too iigroi' ft. ft kvY c 20?4
Facility/Owner Name Facility ID#(if applicable)
/33/ /L'l ..)•/ t'tdki11 v;./Ie,t ft ft
+/1 ft. ft
l ic Phys //l Address,
�Ci ,and Zip i
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field,one lat./long is sufficient) `t 22.Certification:
3 �i p i �' ( N O Or 7 T 6 W �/ �J ,2 V
.r/
6.Is(are)the well(s): IIYermanent or ❑Temporary S gnature of Certified Well Contractor Date
By signing this form,Ihereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 11 o 15A NCAC 02C.0100 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 been provided to the well owner.
repair under#21 remarin 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-11 needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1 L L (ft.)
For multiple wells list all depths if different(example-3Q200'and 2®100') Submit this GW-1 within 30 days of well completion per the following:
�'yy 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: u (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: (in.)Blt Off: 13
24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: `-%` ' /g)7 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
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield m 3 Method of test: f i -7i/ Permit Program,1611 MSC,Raleigh,NC 27699-1611 C��
(gP ) Date Site Visited: " — 2i'� 'ei,. ,vvi
0 o sue-
13b.Disinfection type: 70 hth Amount: �L OZ Site Visited By: /) J ..
Ctiptx.LF ®v r
µ,GC '4zle'
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018