GW1--03248_Well Construction - GW1_20240528

VV1 CONSTRUCTION RECORD (GW-1) For Internal Use Only: --K)
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1.Well �
Contracto nformation: Xj1
Clod Y PO S r14:WATER ZONES
FROM TO DESCRIPTION
Well Contractor e519 ,73ft- a ft St74'-1- sib* S C Mc C1
cJ ft. ft
NC Well Contractor Certification Number :.15.-DUffit CASING(fOr'mrlltl=eaiied:weUL)ORLINER(tfap liciibl`e):'
Yadkin Well Company, Inc. FROM TO DIAMETER THICKN SS 1 MATERIAL
ciF
ft. ft In.
Company Name
q "'��'“'/��'WORMER CASING:O&.TUBING(Reath/IOW r]osed=13op)"
2.Well Construction Permit#: p P. YV L ,�a M 3 0 1-&aCkt FROM TO DIAMETER THICRNESS MATERIAL
List all applicable well construction pelmrta(Le.UIC,Cormry,State,Variance,etc.) ' . ft ! o._.)fit te Viel in. cj,A e 2' �Cj
3.Well Use(check well use): ft. ft in. v V
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft in.
OGeothermal(Heating/Cooling Supply) lil esidential Water Supply(single) ft ft. in
❑lndustrial/Commercial ❑Residential Water Supply(shared) ;18.GROUT
[Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. '_1 ft
❑Monitoring ORecovery ft. it.
Injection Well: ft. ft.
DAquifer Recharge _❑Groundwater Remediation
119.SAND/GRAVEI:PAt3C(rf applicible): •
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL _EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft
OExperimental Technology ❑Subsidence Control ft. it
❑Geothermal(Closed Loop) ❑Tracer ti>26:D GROG(attach'additional slieetaif nedteisiiiy')
FROM❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) TO DESCRIPTION(color,hardness soi]froek type grata dae etc.)
Date Well Started,_ Sj 0 f- ( ft. �i k
4.Date Well(s)Completed: s�')S 1‘A Well TM10!)- q 74 91t. iill ft SOT} 3(aer. 2 1 1L
5a.WellLocation: Phone#: . -.26C- 72 8 1ft. /_u/^ irate tj F 3 s
G 64.y ! c.S + ft ft V •
•
Facility/Owner a Facility ID#(if applicable)
ft ft :,.,�. 't...I `/, +...�..
2.30 Ats-I- P. d j_9a 1-` w 9 4 Nf'„ it fit MAY :% 2624
Physical Address,City,andtip �j ft ft
;215R4M R11
S'-. . ?' 11,..... ,a ... .y.�... ..
County u kV)/
Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 6
(if well field,one lat/long is sufficient) 22.Certification' 1 X
3G.. S37$z' N et.gz33k' W etel 7( S-1-9.,t1
6.Is(are)the well(s): Il ermanent or ❑Temporary Signature of Certified W ontractor 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 iSi ISANCAC 02C.0100 or 1SANCAC 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#2I remarks section or on the back of this form. i
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(W-1 is needed. Indicate TOTAL NUMBER of wells (add Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: N24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1 0 (fit) Submit this GW-1 within 30 days of well completion per the following:For multiple wells list all depths if different(example-3(4200'and 2( 100') C
ii
24a. For All Wells: Original form to Division of Water Resources (DWR), "
10.Static water level below top of casing: 5 el (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 .F-
If water level is above casing,use"+"
Q q 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (p (in.)Blt Off: 5 e ! 1 Program,1636 MSC,Raleigh,NC 27699-1636 1�
/tom 12.Well construction method: Al r roxbry 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: i i 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
5I Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
c ` Date Site Visited: /0 - 23
13b.Disinfection type: 70�o hth Amount: 1 OZ Site Visited By: 0 5-/3
Form GW-1 ?'I".""---'`Ina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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