GW1--03263_Well Construction - GW1_20240528

6
W.„ '" CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
U-0 V " `4 1 I 1 f,f!/�-1 1k i l I r i4.WATER ZONES
Well Contractor lame FROM TO - DESCRIPTION
us 66 -f ft. 125 ft I.2S yfN.
ft. ft
NC Well Contractor Certification Number 15.OUTER CASING(for mtilt rased wells)ORLINER if a licahie: Cr
Yadkin Well Company, Inc. FROM TO DIAMETER TIIICICNESS MATERIAL
.1. 1 ft G 9 ft. / .►t S in. S - 2 1 1 VC,.
Company Name I►�c e LA .D a '' 7 0 0-a 0- 1 7@ 3 �7 D
7 16.INNER CASING OR TUBING.(kliothermal closed=loop)
2.Well Construction Permit#: 2 e�2 S- 3 V'7 0( FROM TO - DIAMETER THICKNESS MATERIAL `hy
List all applicable well construction permits(Le.U1C,County,State, Variance,etc) ft. ft. in• C-C
3.Well Use(check well use): ft ft. in
tW
Water Supply Well: FRO CR TO DIAMETER SLOT SIZE THICKNESS MATERIAL,
❑Agricultural ❑�Municipal/Public ft. ft in.
❑Geothermal(Heating/Cooling Supply) PAesidential Water Supply(single) ft ft in T
❑IndustriallCommercial ❑Residential Water Supply(shared) : la:GROITl'
❑hrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: V/\ 1 ft. 21, ft. . e 1;1 ` e �, 1 L
r f op3
❑Monitoring ❑Recovery ft ft
Injection Well: ft. ft
DAquifer Recharge ❑Groundwater Remediation
i 19.SAND/GRAVEL PACK'(if applicable)
U Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology OSubsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer '20.DRILLINGLOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/retie type,min size,Ste.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) �"
Date Well Started 09 - 1}'Z"I G ft. 4 7 ft. 0 l„.f
SAY cj
4.Date Well(s)Completed:04•2IA- • t`VI wellm#A.A . o C 4 a ft. ,'9 ft �ra � .+ 20Z4
5a.Well Location: Phone#: Zv'�-- 3 - /09-• t d ft. i 2 1 ft ti..,±
a.k'f'Mail, 11.4 l l i A 112E ft. 12 t ft. rs,c cFw� l�.c t Garr e Poi k'Qt�
Fyaccilii y//Owne/r Name, Facility ID#(if applicable)/, 1L'L47 ft. u u 0 ft. s d ILp (�1wA`f
T P9 4C�4�IN14f , 1� ls4 S-/-41c..l� iLa,We '1 i I ft LIu0 ft. 60 MG/'1a arly�r�l'�e
Physical Address,City,and Zip egtZS ft. G ft.
11.REMARKS;". `..
� �� 12S CAPE 4•, L S h. 1-e.r c p c/(t +
County Parcel Identification No.(PIN) �� 17
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: /%O I a i i i I • } •11 l r 5 of f_fe
(if well field,one lat/long is sufficient) 2 .Certific.tio>f
11; TC 0 i2- N •S'jl. Q1 4t3 9 w
• - "irl Alla____ 04 - 2-t1 - / 4
i.
6.Is(are)the well(s): aermanent or ❑Temporary ature of ified Well 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: [Wes or GN o 15A NCAC 02C.0100 or 15,4 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#21 remarla section or on the back of this form. ill
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 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: C O 24.SUBMITTAL INSTRUCTIONS
`
9.Total well depth below land surface: U O (ft.)
For multiple wells list all depths if different(example-3Q200'and 2Q100) Submit this GW-1 within 30 days of well completion per the following:
0 1..).; 24a. For All Wells: Original form to Division of Water Resources (DWR), 41.
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 N
If water level is above casing,use '"+"'
11.Borehole diameter: (in.)Blt Off: 0
24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC) G-
Q,l Program,1636 MSC,Raleigh,NC 27699-1636 l"
12.Well construction method: 1r. r'[�TG✓ 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: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) t 1 • 12 5 Method of test: G1 r t.L�j pi, rev ryst�'
o EA Date Site Visited: i1-27 -Z4
13b.Disinfection type: 70�o hth Amount: v, OZ Site Visited By: JJ,r4
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018