GW1--03267_Well Construction - GW1_20240528

' WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1./Wee�ll Contractor Information:/ 1 Q4 J\t:t U.) Il.ir-›C✓I/• i,1di P AMM'ZONES_'.
FROM TO DESCRIPTION
Well Contractor Name
3636 A ( 36 ft. 134 ft l qt'.
3f01"" Oft 2-X ',""
NC Well Contractor Certification Number :li`ouini, G:(f6"zmiilti"cased:cve.110:ORL]NERiariili Beal le):',
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS 9 MATERIAL
ii ft. (, ft 10 in. airC
Company Name
/���
z,167 1'INNEICCASING:OR', ING iattiiimaPdd'iid.:18`0 .
2.Well Construction Permit#: it°. 1 q C J FROM TO • DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) +l ft. 1 h e71 ft —7 in. / 0 ]T�_t t
3.Well Use(check well use): it, it in
Water Supply Well: FROM PTO DIAMETER
SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft in.
❑Geothennal(Heating/Cooling Supply) residential Water Supply(single) ft ft in.
❑Industrial/Commercial DResidential Water Supply(shared) ,. ,. .,. .. 1
❑hrigation ❑Wel1s>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT g
Non-Water Supply Well: ft. ft
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft ft.
DAquifer Recharge ❑Groundwater Remediation
j`19.SAND)/GR' VF T'ACK'(if:spplicab`Y'e)'' .
DAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD - •
DAquifer Test ❑Stonnwater Drainage ft. it —
❑Expermental Technology DSubsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer 'I20:DRIf,LING-LOG(sittichidditionaYsliietaifnecrssify-1.'.`. .'1 -
FROM TO DESCRIPTION(color,hardness,soli rock type
❑Geothemral(Heating/Coolin�Return) ❑Other(explain under#21 Remarks) grain size,eta)
Date Well Started �,2- � �'
4.Date Well(s)Completed:, ---1-2-y WellID#AA (O y� ft. t l ft. C.,i 3 L( ft. j ft .l;r
( ec,,.,t+/
.er C.1 •c-y,ric4-y1.-.)„S rpcA.
Sa.Well Location Phone#:33C,g0, 1 z�-7 y 1 ft. 6.3 ft fYa,,tI° j„`
.I i1 C.l C(e ow G 3 ft. 7.7 ft 9r^u4.1L,c.,t
Facility/Ownk
-1 Name/� /s/Facility ID#(if applicable) / 7 3 ft t ft r y�n r ( r
(i T I 1, eak-Creek �.kltc e,,, hJ 'iIlee, �J f "� ft 91-4v10 WC(4n-4.-e vi:t:(l
Physical Address,City,and Zip NJ f 13 0 ft. 44/ ft -.1- ,4�
21 REMARKS,.' '...,�� ,
Da Li I cr
County Parcel Identification No.(PIN) . .=c. t -, u, '
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: isll AlS 2024 <
(if well field,one lat/long is sufficient) 22.Certificatio.'
r
trgi .PZ1112: — '
� Signature of C .ed Well Contractor Date
6.Is(are)the well(s): D ermanent or OTemporary
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 MV o I SA NCAC 02C.010D or 15A NCAC 02C.0200 Well Construction Standards and that a copy
(71
If this is a repair,fill out brown well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remark 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 Gwp-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 1 - ( 24.SUBMITTAL INSTRUCTIONS
/� �
9.Total well depth below land surface: T 7 2 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2®100)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (it.) Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617 -
If water level is above casing,use"+" j
n 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC) ro
11.Borehole diameter: lG n (in.)B It Off: - -1�{0Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: ,4// £1t'` p`J 14 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
V
13a.Yield(gpm) 2 5- Method of test:t 2_1 z 2
o Date Site Visited:
13b.Disinfection type: cf
7O�o hth Amount: 17 OZ Site Visited By: 0373
Form GW-1 '''- "' tins Department of Environmental Quality-Division of Water Resources Revised 6-6-2018