GW1--03232_Well Construction - GW1_20240528

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:1.Welt ontractor Information: ` M /. '
U LAY t ! j/,�� (f 'j(t/t f �- TO"i4:MATER ZO S
FROM DESCRIPTIONWell Contractor Name ^ •
1/�t 6 ft. ft. (J 's
4 S •!//o- / tin it 8 �
NC Well Contractor Certification Number 15:OUTER CASING(for coati ersed'wella)ORLII+(FF�t Cdap hie)
Yadkin Well Company, Inc. _ ' ft I TO ft I DIAMETER;n 1 THICKNESS1 MA CC
Z 22 t VC,
Company Name ' 16.INNER CASING OR T[IBING(geotliermal doaed=loop)
2.Well Construction Permit#: O L 9 . I ` b 2 1 FROM TO . DIAMETER 'THICKNESS MATERIAL
List all applicable wrll construction permits(i.e.UIC,County,State,Variance,etc.)
ft. ft in.
ft. ft in.
3.Well Use(check well use):
F7.':gCIiEE
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural ❑�M/unicipal/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) leesidential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) : 18.GROUT
❑Wells>100,000 GPD FROM TO ,MATERIAL EMPLACEMENT METHOD&AMOUNT
❑on-Waon 8 ft. /�' ft ( Q 11e �.e 5 (Gov 1 �
Non-Water Supply Well: "'-"tl]""�v� "'�l�
❑Monitoring ❑Recovery ft. ft
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation i 19.SAND/GRAVEL PACK'if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
ft f
• ❑Aquifer Test
❑StormwaterDrainage t
-
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer '20.DREtT_INGLOG(attach additional sheets if necessary) 7
FROM _TO DESCRIPTION(color,hardness,soS/rock type,grain size,etc.) <
I1[ ❑Geothermal(Heating/Cooling Retain) ❑Other(explain under#21 Remarks) Q ft �� ft re 4.4 kaj/
Date Well Started y �� - Qp�( �
4.Date Well(s)Completed:1'(-ft- Well ID# S ft. -2 7 5 ft. �;e O.rO.
Phone#:630 -33 ft- y)J9 3 6 ft L/ 0 ft bro t,,,yv (Zok A- i"-) c,
5a.Well Location: 11
�k rev 4 t ft. 6 4 ft QroAta� _3,
�t urner - t C ft. zc z ft J s �9,Gw/
Facility caner Name (� i e� Facility ID#(if applicable) f1 y�j (,�J
44(4) PG„&j, lid g.O.J 1 BL'-i tsiC of (®7 D ft. ft.
Physical Address,City, Zip
21.REMARKS_;
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 i ca..n:
i:. '�,, ed Well Contractor Date
6.Is(are)the well(s): rmanent or ❑Temporary
By signin:.his form,I hereby certify that the wells was(were)constructed in accordance with �{�►
7.Is this a repair to an existing well: ❑Yes or 1!1 ISA NCAC 02C.010D 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. X)
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details: n
You may use the back of this page to provide additional well construction info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarkmay Box).You also attach additional pages if necessary.
drilled: / 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q200'and 2Q100')
%i‘ 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 6 Li (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
S 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.)Blt Off: -�+(� �r Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: at r. ' y 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(gpm)
/>l 41'9e -"47 t r. Permit Program,1611 MSC,Raleigh,NC 27699-1611
o h Method of test: v Date Site Visited: a-2-7-23
13b.Disinfection type:
70/o th Amount: 1? OZ Site Visited By: pin /t1• y.1a i4e-
l4 j 6, L}• Nra .1-i:.
Form GW-1
North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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