GW1--03241_Well Construction - GW1_20240528

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
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1.Well Contract Information: CI_
<-40I,4'1 IT641
,7a4.WATE1YZONES •4_>.: - . Iff
Well Contractor Name FROM TO DESrim
RIPTION 0
K�co A • 131 ft. ft.
2t5'7 ft. V. ft c f. S
NC Well Contractor Certification Number q( `
15.'OUTER C 1.SING'(foimuld-'cesed'Svefl RIINEI i(ifap"'lici1i1).7...
Yadkin Well Company, Inc. FROM/ Tp DIAMET R. THI MApRIAL
t. j ft in.
Company Name // (((
i a ^•� p a,16IIIVNF-R:CASING'O1 TUBING:(g"e'otEir derelmed=loop)- .
2.Well Construction Permit#: 1 1) ( I `J\) FROM TO . DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) I ft. 11 21 it. sQ 1'2 i in. 6.125 S ✓) VG
3.Well Use(check well use): ft. F ft CA hi. l D J�'V
Water Supply Well: i7'SCRFE>�,
FROM TO DIAMETER SLOT SIZE THr SS MATERIAL
❑Agricultural ❑Iv�unicipal/Public in. J
❑Geothermal(Heating/Cooling Supply) �Klesidential Water Supply(single) ft (ftL, 7.in. (/
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.'GROUT .
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q ft 2 5 ft. M9 Cblp5 G.`�. l 1 l l y {,,,,,5
(/ %/ V Mf
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation i,. 3AN])7G7i1VFS?It1l Kt rf n hcilble;
❑A uiferStores RecoveryStorage ❑Salini Barrier7C )
�l $ tY FROM TO IKATERL EMPLA METHOD
❑Aquifer Test ❑Stoanwater Drainage ft. ft. /
❑Experimental Technology OSubsidence Control ft. ft (/
❑Geothermal(Closed Loop) ❑Tracer ''20.DRICL1NGLOG(attach i.dditio'ni1aHeete if necessary) • ..
❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rack type,grain size,etc.)
❑Geothermal(Heating/Cooling Return
Date Well Started 11-1 2 Q /�33y it ft. e ►t,, 1 •'5
4.Date Well(s)Completed: 7•C( Well ID# '• V /� ft. it ��,,yes ���
sa Well Location: Phone#: jb- t,'�-(g](9 3�it 53it. 1�rftwh W AO lc1 /kn,� #
�� \\ /5 // I./3 o i� r is. e!\C.2 2 I S ft. 3 G Lt' 111�,I 50�- rock- Pte./crab G-
Facili Name/ Facility ID#(if applicable) ft. ft. . _ ®()
kw/ zg ikn tKL5OO O,IX ac6 l991 ft ft. j , .._ ..: _.
Physical Address,City,and Zip ft. ft. a, i
104. . +i.a 2118aufrc
County Parcel Identification No.(PIN) 1 L:•...'•,.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field,one 1at/long is sufficient) 22.Certification: , '`
` l9' 1��� N �`• �Vk�� W -:5;; -1 (� Li./se- 2
ti
6.Is(are)the well(s):`Permanent or ❑Temporary Signature of Cert fed Well Contractor Date 141
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with r"
7.Is this a repair to an existing well: ❑Yes or 1 8Vo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information an�explain the nature of the of this record has been provided to the well owner. -tom
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details: r.)
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this pag•s to provide additional well construction info 4,
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).Yin may also attach additional pages if necessary.
drilled: l
` 24.SUBMITTAL INSTRUCT TIONS
9.Total well depth below land surface: ..L (ft.) Submit this GW-1 within 30 days of well completionper the following:
For multiple wells list all depths if different(example-3(a1200'and 2 a@100) y' P
10.Static water level below top of casing:
I Q (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Tnformation Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
L 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.)Blt Off: Jr t�� Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: f(ey Liit( 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) f3 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
1 Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) V. S Method of test: A i f f o7Y
70% hth / Date Site Visited:
13b.Disinfection type: Amount: -1 OZ Site Visited By:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
Price: o?-3al.it 11,11,.,/ e Sen., gnu.