GW1--03238_Well Construction - GW1_20240528

j +�LIQONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor nformatiQn:( t /�, MAI / , C�'' �.�(>� WW t 1 1 (�l ` l i J —r r.'14.WAz ZONESYFROM TO DESCRIPTION ^,
Well C,og�tor Zam6e^ �/ ,UfL l{ 75e ft 55 t` /v1
YY PE-
ft. ft.
NC Well Contractor Certification Number 15:OUTER CAM:RG.(fu-r multl ted wells)ORLINER(ifa' llcable) �.�q
.
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL t l
I ft. 9 L( ft�/ i 1 Z ei in. �ps .-it P tic_ :7.;Company Name 1 li 74
O ' SINNER CASING.OR.TUBING.(ge'titliarmal cloied3oop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft• ft. in.
RI
3.Well Use(check well use): it ft to --}�
Water Supply Well: o H TO DIMSSTER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑_M//unicipal/Public ft, ft in.
❑Geothermal(Heating/Cooling Supply).' '; (Residential Water Supply(single) ft ft in.
❑Industrial/Commercial ' a. ' '''-tlResidential Water Supply(shared) :• 18.••
GROUT
❑IrrigatioII ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Suppi ''�n.Il:�' s, ! 0 ft 1 7 ft 17 rNo1 I C 1 :p 4 f t sir 17
❑Monitoring , . tikecovery ft. ft.
Injection Weil: ft. ft
❑Aquifer Recharge .❑Groundwater Remediation
DAquifer Storage and Recovery 0 Salinity Barrier l FROM SAND/GRTOVFd'rEAC} "(MATKRL L)'. EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. IL
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRItXINGLOG(attach additional sheets if necessary)
FROM❑Geothermal(Heating/C ling Alum), L.DOther(explain under#21 Remarks) TO DESCRIPTION(color,hardness soil/rock type grain size etc.)
Date Well Started 01 — / I- 0 ft 40 ft c ih
4.Date Well(s)Completed:0 4—Z 2*Z.' well ID# 4\ 100 h 0 ft 7 S ft* 0 i
5a.Well Location: Phone#:.176,—C147-3/510 7 6 ft. 9 1'1 ft A t e"r ii C
.c 1'''i WI.‘ R.c021, Prn. c,7.4.4. cc.,,krt.v.4-,..„, 8 5 ft i W O IL J S O 1-i- `F!tJ 5,„:„.il__
Facility/Owner Name Facility ID#(if applicable) I I/ ' ft. S Z Z fL S ()T Qi t':Mtt•I e
/,t_ &1 —0.vvrvvort.8 11Ci.?.3 118
ft. ft
ft. ft.Physical Address,City,and Zip
21 REMARXS
ail�k� s
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutea/seconds or decimal degrees: iki. n
(if well field,one lat/long is sufficient) 2 ' cation: (�
3 C., 3609 t . `I N g / 7 Sl--t." W i Us 1 . 22 - Z _I
6.Is(are)the well(s): 21fermanent or OTemporary i tore Well Contractor Date
ape
signing this form,'hereby certify that the well(s)was(were)constructed;.e accordance with 5,
(OF
7.Is this a repair to an existing well: DYes or 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standa ds and that a copy
tr
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#21 remarks section or on the back of this form. 23.Site diagram or additional well details: 6
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
You may
(add'See Over'in Remarks Box). also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells0
drilled: 24.SUBMITTAL INSTRUCTIONS
S
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 1Q100')S �`` 24a. For All Wells: Original form 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"+" i ,
24b.For Injection Wells: Copy to DWR,Underground Injection Control(TUC)
11.Borehole diameter: (in.)Blt Off: Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: `r Pu Or y ui
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the N
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed A"
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA ...11,
5 /'a t Permit Program,1611 MSC,Raleigh,NC 27699-1611 06,44
ao'
o 2 Date Site Visited: 1—Z9-2yl
70/o hth (� OZ Site Visited By: J)
13b.Disinfection type: Amount: 3 -
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018