GW1--03233_Well Construction - GW1_20240528

,,,,fIE W1+LL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
J.Well Contractor Information: ��/� )---
dy W1 i I I j+Vr - t in ( /, $ f 514.FRO WATERM ZONESTO _DESCRIPTION
Well Contractor Name "57Oft. ft S n ',,,�
C, 6 /4 00 �J'f 1 , V
ft. ft
NC Well Contractor Certification Number 15.OUTER CASING(for multicased wens)OR L INER gip licahle) �,!��
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL l�
{. 1 ft. 1 6O ft 6 2 l in. (h1v y�1V�1 ' 4 c I K
Company Name '16:INNER CASING.OR TUBING(ge:ithermdclosed loop) I •n'
MATERIAL
2.Well Construction Permit#: ®1�� / FROM TO DIAMETER THICKNESS
� 3 ft, ft, in.
Listall applicable well corutrvction permits(i.e.UIC,County,State,Variance,etc) �.
ft. ft in.
3.Well Use(check well use):
Water Supply Well: �iZ'SCREECT.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural 1 ❑MMuunicipaliPublic ft. ft in. .�
❑Geothermal(Hetiting/Cooling Supply) LKesidential Water Supply(single) ft ft. in,
-
❑Industrial/Commercial ❑Residential Water Supply(shared) 18:GROVI
❑hrigation ❑Wells>100,000 GPD II FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. S'-ft. Cpieri}f 18U:r
❑Monitoring ❑Recovery ft ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
i 19.SAND/GB:AVM:TACK(if aliplielible)'.
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermai,(ClosedLoop) ❑Tracer 20.DRILIIIG LOG(attach additiornl sheets ifnecessary)
FROM TO DESCRIPTION(color,hardness,soWrock type,grain size,etc.)
❑Geothermal(Heating/Coolin R DOther(explain under#21 Remarks) ft .1(3 ft. C la
DateNell Started 3 AA /^� c,
4.Date Well(s)Completed 3 'Z ' t Well ID# AA -9 : 1 1 ft. 7 s ft. L t{t d.yr.1- 1
5a:Well Location: Phone#i`-:. .9"1 .• it /.3 '7 i ft. ' ZH ft `( 4 Q- d i r T Sot,.d vJ wk T-
334 ,S3G - io ft. ft• frrc.4.w'. w0,k
Al � t Mf��.�tLSCC l�� � 2S � 37
/Facility/Owner Name Facility ID#1(if applicable) 1 '2 J j2 ft. 1 f Q ft. St lC r.di•7 i
7zG�' 6M iel-Nk f tV::1 [=tic J g . .
. .1 C, 4 s 1 ft 3 l V ft 1•644 ram,•#.'t. .
Physical Address,City,and Zip ^7��® •
3 O ft. t�(/r, ft _wt�,�N7 Me 9fw�/M R.
Kid d C it �( ® 21r REMARKS L v ,`�`�C
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) s 22. l ratio:
V' es
., aa2i. 0
/� •e of C'' ed Well Contractor Date
lli�r
6.Is(are)the well(s): manent 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 15A NCAC 02C.0100 or 15A NCAC DC.0100 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. .V
repair under#21 remark section or on the back of this form. 5
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. o-
drilled: / 24.SUBMITTAL INSTRUCTIONS Ct
9.Total well depth below land surface: "'{ 44°o (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3(200'and 2@100)
24a. For All Wells: Original firm to Division of Water Resources (DWR),
10.Static water level below top of casing: V (ft•) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
Z 0 L 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.)Blt fit,
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: &( r \�t, i-Gr 'i 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct pusli,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WEI IN 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_ Method of test: �/�.Ai� �
e hth Site Visited: 12-Z9-2 3
70/ Oz Site Visited By: fl'�3
13b.Disinfection type: o Amount: --- ro
4.
Form GW-1 E\ _____Notth Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-201 8