GW1--03229_Well Construction - GW1_20240528

' WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contra tor Information:
`J{r 1 t•��M I 1 e ? �1 ;,14:WATER ZONESi'VV (\IV / FROM TO DESCRIPTION
Well Contractor Nah a /� ft. L ft. Lc,G A I ft. Z1S ft S : �
NC Well Contractor Certification Number 15.OUTER CASING(for multi=cased'weIls)OR LINER(if ap licab /�
le)i ` ,
Yadkin Well Company, Inc. FROM T DIAMETER THICKNESS MATERIAL S
.t 1 ft. g B., ft. [ 1 a '; in. jDti ' L, 1 10V( .i^.
Company Name r�^�+II(�. 7 ''16i INNER CASING OR.ToBING�((ge stheimal dosed:loop)" ' V'
2.Well Construction Permit#: V(cS 14•3- - 20 L -? -FROM TO DIAMETER TBICIINFSS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)
ft. ft in.
ft. ft in.
3.Well Use(check well use): itiV
_
Water Supply Well: FROM TO DIAMETER SLOT SIZE TIDCI(NESS MATERIAL
❑Agricultural ❑ unicipal/Public ft. ft in.
❑Geothermal(Heating/Cooling Supply) VResidential Water Supply(single) ft ft. in.
❑/�Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
�
�Ttrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
(
Non-Water Supply Well: () ft. , `I it 0;1%1-44r t 00 LAB.
❑Monitoring ❑Recovery ft. ft. r
Injection Well: ft. ft
DAquifer Recharge ❑Groundwater Remediation
119.SAND/GRAVEL.PACK'(if applicable)'.:
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft
flGeothennal(Closed Loop) ❑Tracer 20:DR11SNGLOG(attach'additioiiiil shied-if nicessary)
❑ ther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,sail/rock type,grain size,etc.)
❑Geothermal ng/Go lingR tu�)6 O ft. ft. c Ik .
Date Well Started } Z /� � • ' ', '.
4.Date Well(s)Completed:? "I d `L 1j WellID#44A. 1OCC 2 r ft. 3 it 0 i 4-
Phone#: 3ze. 3R9.2� 543- 36 ft. ,/�' ft t-e <4 S4e I I MAY 1 5 Cf14
5a./Well Location:
CI ss ace',kle.✓ S ft. 2IS fL ''ed Ste 1 (
FFaaciility/Owner Name fi ( Facility
lI#(if applicable) / 2t'& ft. ' (iSft. ro���ffe4t ,
3 7,�'I,.Lf>r,4 d�G VC(Skfmili1 ((e)Ivv a?O5 L4i ft 26Itft tC 4.€ /(
Physical Address,City,and Zip ft. ft.
( 21.REMARKS,
I 61,
0 iL//\
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one las/long is sufficient) 2 .C tifieati N.,e,ci
�. OL2z3.' N Or G Y6.- W014 t 16 -2 ii
Si ature Certified Well Contractor Date
6.Is(are)the well(s): igtrmanent or ❑Temporary
y signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 14,,lo RSA NCAC 02C.0100 or RSA 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#2l remark section or on the back of this form. 23.Site diagram or additional well details:
S.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 q"
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.
coo
drilled: / 24.SUBMITTAL INSTRUCTIONS -..0
9.Total well depth below land surface: 6 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3 a�200'and 2Q100)
u (r..V� 24a. For All Wells: Original firm to Division of Water Resources (DWR),
10.Static water level below top of casing: -! (ft') Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 -_
If water level is above casing,use"+"
24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.)Blt Off: .�+ Program,1636 MSC,Raleigh,NC 27699-1636 -""-.-
12.Well construction method: Aiv d. : R• h Il�� 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
/t Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 2 5 Method of test: (/� i p/�
Date Site Visited:IG 1.-2.313b.Disinfection type: 70%�o hth Amount: I Z OZ Site Visited By: e' C' •
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018