GW1--03268_Well Construction - GW1_20240528

WE IL L CONSTRUCTION RECORD (GW-1) For Internal Use Only:
' 1.Well Contractor Information: ril
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y (O( �IJ 1 L1 � + l ) i 4 WATElt'ZONES': i .FROM TO ' DESCRIPTION -4—
Well Contractor Name
2ft. 1'7ft e frt c v.(`t (vim-Jh CI_w1'Pr�
ft ft
NC Well Contractor Certification Number ®)
;:15f0IITERf'ASIN0(for'mrilti=cased:weili):01CL7NER:(rfa licatile)'`
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL CG
ft. ft in.
Company Name v 7,53- Ci cx -se
1� 33 `:.16iINNF.R:QASING.OR;1'uBWG(gtiot7fermal"closed=lbop)�" :.. . ..
2.Well Construction Permit#: $40 I 7S O 9g- FROM TO _ DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) 1 ft. I ut qft. ()1/LLm• J1�-,. <73 '1, ?t f
3.Well Use(check well use): ( ft. '+l ft in. d
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
:Agricultural ❑M�unicipal/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) QiCesidential Water Supply(single) ft ft in.
❑Industrial/Commercial ['Residential Water Su• pply(shared) •T9 .GROUT — •
❑Irrigation ['Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• kiS ft. ‘ lii Chi e5 2 9 )vet ej ge(i4'lilt
:Monitoring ❑Recovery ft. ft
Injection Well: —
ft. ft.
❑Aquifer Recharge ,❑Groundwater Remediation
1'19.SAND/GRAVFSXPACK'(if;apphcable); .,•.
[Aquifer Storage and Recovery ['Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD - •
DAquifer Test ❑Stormwater Drainage ft. ft.
:Experimental Technology ['Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer :20.DRI.tJNGLOG(attach idditlaril"sheets3f necessary)
FROM TO DESCRD'TION(color,hardness,soll/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
Date Well Started iJ—d.,I.1-7, 0 ft. 1. ft. 56 l 1
4.Date Well(s)Completed: q-am t Well ID# t1�f" !V q
ft 119 ft 5(4 A ail 1,4,-11-4^ed tJ G jV
5a.Well Location: Phone#: �4'-ici-/i-J 79� ft ft
Ke AA,(s.�, I � � ^� -ice �:k�rK y �h)
ft. ft.
Daa." mar f 6iA►(de►, 70�C- Stro sow? —
Facility/Owner Name Facility ID#(if applicable) ft. ft. ,-^ -..
/ ft ft +�•
Physical Addresef City,and Zip NC elOrt
ft. ft. i.l A
Oa V ` '.21?RFMARTCS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one 1at/long is sufficient) 22. rtificatio
3 S q q (s-r N g®., 6 .7 I 3 w 7.
Is(are)the well(s): ermanent or ❑Temporary Signature of Certi ed Well Contrac or Date
1r
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: DYes or n'l(o 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out,brown well construction it formation and explain the nature of she of this record has been proi'ded to the well owner.
repair under#21 remarks section or on the back of this forms.
23.Site diagram or additional wet 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. 16
drilled: i 24.SUBMITTAL INSTRUCI'ONS f
9.Total well depth below land surface: 1o'0 a_ (ft.) 3
For multiple wells list all depths ifd different(example-3(a)Z00'and2Q100) Submit this GW-1 within 30 days of well completion per the following: 0
10.Static water level below top of casing: IQ 24a. For All Wells: Original form to Division of Water Resources (DWR),
(ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: L) t I (in.)Blt Off: ) j. '1 7 / 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
,\ r Program,1636 MSC,Raleigh,NC 27699-1636
Al2.Well construction method: 1 r✓ ( O 24c.For Water Supply and Open Loop Geothermal Return Wells:Copy to the AA
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WFT,T S ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA p
�]�� l Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) T!`V Method of test:
111)
70% hth oz
Date Site Visited:3-Is-2-* c'� 9-12-2..3 -'1-
13b.Disinfection type: Amount: -'L Site Visited By: p7
Form OW-i North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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