GW1--03274_Well Construction - GW1_20240528

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Cr
'VQm J e W Q. e A S i14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION S
-�`Q` ft. / j7 ft e/CPm1
NC Well ContractorD'AS Certification Number ft. ',(!O ft SP GPD N
15.OUTER CASING(for midti-cased'ivells)OR LINER(Kip lidibre) al
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS I MATERIAL
ft, ft in.
Company Name
I 0 ' 16.INNER CASING OR TUBING,(geothermal closed loop)' . /�
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL f\".
List all applicable well construction permits(ie.UIC,County,State, Variance,etc.) { 1 ft. L, )ft, / tif1 in. C/�i^' Ot C.
6
3.Well Use(check well use): 1 ft. _I Q ft. (, in. J'J r
Water Supply Well: L7'S.CREE), 3
FROM TO DIAMETER -SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic ft. ft. in.
0 Geothermal(Heating/Cooling Supply) 2esidential Water Supply(single) ft ft. in.
❑lndustrialiCommercial ❑Residential Water Supply(shared) .18'GROUT
•
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL _ EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. Lf YC ft. f_ �D`•` p¢vrio, ( ' bk5'
❑Monitoring ❑Recovery
Injection Well: ft. `_ 2y ft. vq
Otrtut.Greai Pumee ci LI (c?43$
ft. ft
❑Aquifer Recharge ❑Groundwater Remediation
i 19.SAND/GRAVEL PACK'(if applicable)
❑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) OTracer '20.DRXCEJNGLOG(itlacli additional sheets if necessary)
FROM TO DESCRIP^3ON(color,hardness,soillr oak type,grain size,etc.)
❑Geothermal(Heating/Coo ino Re un) ❑•jther(explain under#21 Remarks)Date Well Started r ft. 3p ft / 7.j /�
1.Date Well(s)Completed:q/ SIX/ Well ID# 4 . i 6 30 ft- yo ft W Cc d'ka(d Rock-
_
5a Well Location:( (� + Phone i#�: • / `; , 10-. •9'4 L40 ft. I,gr. /�S �k.�
GAr * ..5�1.3Ctf f 1- OIbrooks ft. Q ft. l9
Facility/Odmer Name Facility ID#(if applicable) ft. ft.
FA1� G Cry �j/ 1
A/7 YA/7 D g Iv Ct._foil i1 �L 210 6 i� ft. ft d n�' -
Physical Address,City,and Zip ft. ft
_
S hi 21rREMARICS:.'As
• ,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
36, s� 33 N a', 6 3 87 W I (u � i2)
6.Is(are)the well(s):'ermanent or ❑Temporary Signs re ofC ed Well Contractor Date
By signing this form,I hereby certifi,that the well(s)was(were)costs:ructed in accordance with
7.Is this a repair to an existing well: ❑Yes or *o ISA NCAC 02C.0100 or 15A 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 ofthis record has been provided to the wel,'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 G� -1 . needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 'X +� 24.SUBMITTAL INSTRU(:f1ONS
i 9.Total well depth below land surface: 8). (ft.) Submit this GW-1 within 30 days of well completion per the following: IS)
For multiple wells list all depths if different(example-3(200'and 2©100) . .
24a. For Al! Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: d (ft') Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" te
11.Borehole diameter: 6 (in.)Blt Off: Si 9[0 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC) ^t"
Program,1636 MSC,Raleigh,NC 27599-':,36
12.Well construction method: u i I L®+A r p 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
r Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 1 2 Method of test: Lr,L ik t r
70% hth o Date Site Visited: _ -
13b.Disinfection type: Amount: '1 OZ Site Visited By:
Form GW-1 North Carolina Department of Env ipmnental Quality-Division of Water Resources Revised 6-6-2018
Price: c -reZU}