GW1--03258_Well Construction - GW1_20240528

Wf"CONSTRUCTION RECORD (GW-1) For Internal Use Only:
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1.Well Contractor In rmation: l)
�J o(;/y) ISI?/ 1'1(4 / !i'S 3\� LI 4.WATER ZONES :
Well Contractor Nffine(4 5 4 4 -4 ft 193 ft to
FROM TO DESCRIPTION
ft. ft.
00
NC Well Contractor Certification Number .15:13ITER CASING(foi•multi-ciiiied wails)OR LINER(d°a-p livable)
Yadkin Well Company, inc. FROM TO D ZE , D�ESS r MA AL
cam^ f ft. S ft in.
S 1-` f tit C
Company Name �'• 2(6- $f 2 V /
�v'� � ryy 7 'e16SINNER CASING:OR.TDBING.(geotharmal doffed=loop) it
2.Well Construction Permit#: 1 z I / FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well con cur rction permits(i.e.U1C County,State,Variance,etc.) ft. ft. hi.
3.Well Use(check well use): ft. ft. in.
l'
Water Supply Well: 07.S� '
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL 1
❑Agricultural ❑ crpaUPublic ft ft in.
❑Geothermal(Heating/Cooling Supply) ldential Water Supply(single) ft ft in
❑lndustrial/Commercial ❑Residential Water Supply(shared) 185 mow tA
cA❑Irrigation ❑Wells>100,000 GPD FROM TO i i /MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fr. 2.01/it ; C�1(J)D (i/ 3 s 1'alC'
❑Monitoring ❑Recovery ft. ft '�
Injection Well: ft. ft
t
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVELPACK(if`afenlii_able)`
❑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.DRMLINGLOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soil/rock type grain size,etc.)
Date Well Started O K"3 U •�1 rt.'.. 2ti ft 0 t r F.
4-0,-(4-
4.Date Well(s)Completed:FJ f-0 1-24 Well m# AAA- 12? 2 t ft 6 S:: ft 1 C Q,(, 1/-L /n`e C is Groat(
5a.Well Location: Phone#:3 o"QDq_ 0377 ` ` ft. 7 S ft re,. f t r /
fr. ' V ft
R. v-Z Mernev a Cve*k jay M ) 7 g d r04 .
Facility/Owner Name Facility ID#(if applicable) �.y 1 9 1 ft' 2 6 rJ fr' S Q Vri fQ
' r`a,.,d t L
r4i Gve Malr.r
f Wwd,lea i, �v r ft. ft. �/
Physical Address,City,and Zip ft. ft. . .. j.4
it/�l 2tREMARKR 1 it i_-. i
6 Wavy G'''
County Parcel Identification No.(PIN) MAY •r S 2024 w\
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (+—
dwell field,one lat/lo is sufficient(' d, rig� ) 22 •• ti5ca�o�. '�;)
Is--- -2 if( N �o1 ( Y- 4 w k/ Wrm ii 0..s.
J ;JZ - 'l
.dr:t6.Is(are)the well(s): [ rmanent or OTemporaryure of C ed Well Contractor Date
Pe
By signing t form,Thereby certify that the well(s)was(were)constructed in accordance with
,
7.Is this a repair to an existing well: ❑Yes or �Plo ISA NCAC 02C.0100 or 154 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 MIS 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:
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 GWW is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
01
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) Submit this GW-1 within 30 days of well completion per the following: 1
For multiple wells list all depths if different(example-3@200'and 2Q100) ("
2 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: J 0 (ft') Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
24b.For Injection Wells:Copy to DWR,Underground Injection Control(MC)11.Borehole diameter: /�(m.)Blt {Off: Program,1636 MSC,Raleigh,NC 27699-1636
A.12.Well construction method: i r Rid--AI'224c.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: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
/i � Method of test:_ 1tL
t
// )r Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm)
o Date Site Visited:2'1-Z Y
70% hth �., Site Visited oZ D.
13b.Disinfection type: Amount: By: D d
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018