GW1--03237_Well Construction - GW1_20240528

WELL CONSTRUCTION RECORD (GW-1. For Internal Use Only: 1
1.Well Contractor Information:
11
;:k ill 1 tr l 1 t �14 WATER.ZONES'_'.< $.1
Well Contractor Name • _--' •
_ FROM TO DESCRIPTION
,�yy �... . 1._••
/5-0 ft. 5'8�1 ft avRo-k ?
1+
7J1'!7 ?AAI ') 5 ��24 S'Yo f- Vac• f. Devl� ?
NC Well Contractor Certification Number rl
is 13?OUTF.I>,"CASING(foiliiiilfi*Eed'SveIIs):ORI.TNF,I;;(ifstp licalilef. Cai
Yadkin Well Company, Inc. , FROM TO DIAMETER THICKNESS MATERIAL
ft, ft. in.
Company Name
D q r` A W 1CINNER;CASING OR IAIS NG(ge'itSermal closed=loop)' .
2.Well Construction Permit#: FROM TO . DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(ie.UIC,County,State,Variance,etc.) I ft' /6 u ft 10.1;xi.•in. 6 Y0R' 't Q"
3.Well Use(check well use): ft. it in.
Water Supply Well: c I7iSCRFEI•);
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) 001.esidential Water Supply(single) ft ft in. N
❑lndustsial/Commercial ❑Residential Water Supply(shared) ,. - S.
1B:'GROUTi:: r.`:. 2.
❑Irigation :Wells>100,000 GPD FROM TO MATERIAL( EMPLACEMENT METHOD la AMOUNT V
Non-Water Supply Well: D ft. C�r ft. ,IJ61,C:t,t, y Qv in
di
❑Monitoring DRecovery ft. 7 it
`pJ
Injection Well: Li 1 �L/ 8r, -Sh.h""1 ai.atrde '1`
ft ft. r .fri.
❑Aquifer•Recharge ❑Groundwater Remediation
j`.19.SAND/GRtlVX1+PACw ofirlap able - J,
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL� EMPLACEMENT METHOD '
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLINGLOG(sittieh iddifia"nal sheeti if'inceisaiy)';':''. _;.:-...1. . i, ;.
FROM TO DESCRIPTION(color,hardness,sotllrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
Date Well Started '-i. 2 f.✓ O ft. ?cif i' ft .Se i
4.Date Well(s)Completed: S'- '.�+. Well ID# 7
919
Q '"-� AA_ -��^� ft as-0'ft* Meg ce+ iv „Co 64ey
5a.Well Location: 1 I-1'341-R lalhone#:.3 31a 4309 -037/ v) ft. y/0`ft pie/
,, /,.4 / Ares. ii kids.'
S/� 1 q t�( i� 7te ft. �.®0 t -54P• C
1 m + ` �/l ( W L.s+ 1�4Vi'l ,�ru�tA /I/� "�v` /
Facility/Owner Name Facility TD#(if applicable) ���►0�01R' Ci�®.ft. �edr.Jas YiOnte- (Lj01 A red'�i,l
�14 J 6r,��Ps'4a„e, L4 .M;t'/us Gt4t, 1�"` ` fft" i1 E4 ft ilvel S:U.r' �/" rt.k
Physical Address,City,and Zip a U s i ' ft. ft
I,v ; j kts U19
County Parcel Identification No.(PIN) ic ,f / / .) /�V 5 6 e
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ft-
r�7�� °5 V'` V
(dwell field,one 1at/long is sufficient) 22.Certification: ci d Q- - Q Z/50
!
3b . 2y31`I N VI, 3.,119`1 w J CI)PI
6.Is(are)the well(s): •Oermanent or ❑Temporary Sip . c of e W Contractor Date
By 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 )1(No 1SA 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#11 remarks section or on the back of this form.
23.Site diagram or additional well details:
?L`
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 Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS A
9.Total well depth below land surface: �/ fq (ft.)
For multiple wells list all depths if different(example-3200'and 2Q100) Submit this GW-1 within 30 days of well completion per the following:
} ( 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: �� ft) Information ProcessingUnit, 1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" !' .
11.Borehole diameter: (in.)Bit Off: 6
-t 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27 699-1 63 6
12.Well construction method: 4i r roll'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 ON Y: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) .1l A Method of test: r�S 4 i r Permit Program,1611 MSC,Raleigh,NC 27699-161)
70% hth Date Site Visited: a/a sn i .
13b.Disinfection type: Amount: YS OZ Site Visited By: M[J
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources [7 Revised 6-6-2018
Price: