GW1--03276_Well Construction - GW1_20240528

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractora Information: a)Ali 1..I.- eGoLtre 4:WATER ZONES . _
•
FROM TO DESCRIPTION y�
Well Contractor Name 3 ti-sit ✓a. 3 ft V
J Sk?--A J �1ft. ft
NC Well Contractor Certification Number `15.OUTER CASING(flit multi-cased wells)OR LINER(if applicable)
Yadkin Well Company, Inc. FROM TO DIAMETER TRICKINESS I MATERIAL _
ft. ft in.
Company Name
3S 2.Well Construction Permit#: C
6 11 8 7_ '16:INNER CASING OR TUBING(geothermal dosed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(I.e.UIC,County,State,Variance,etc.) + I ft. t 2q ft C,O,s—in• S ORw _PVC
3.Well Use(check well use): ft. ft in.
Water Supply Well: 17:SCRi .
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipailPublic ft ft in.
❑Geothermal(Heating/Cooling Supply) Xesidential Water Supply(single)
ft ft in.
❑Industrial/Commercial ❑Resid• ential Water Supply(shared) : is.GROUT
❑iIIigation ❑Wells>100,000 GPD FROM TO MATERIAL. - EMPLACEMENT METHOD&AMOUNT_
Non-Water Supply Well: 0 ft. 25- ft iefi I.L,'; di 1 �b►rs /
❑Monitoring DRecovery f. ft. T I b5 i /�
Injection Well:
ft. ft.
❑Aquifer Recharge 0 Groundwater Remediation
i 19.SAND/GRAVELPACK of applicable) •
❑Aquifer Storage and Recovery ❑Salinity Banter FROM TO MATERIAL EMPLACEMENT METHOD '
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control ft. ft
0 Geothermal(Closed Loop) ❑Tracer 20.DRII,LTNGLOG(attach additional sheets If necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(minx,hardness sell/reek type,grain size,etc.)
Date Well Started L _j2- ZH O ft. r'l!1 ft ('O ` ' /
4.Date Well(s)Completed:4-43-).17 Well D)# A Ae- iS3 f'4 it. 5)D'7'?' It
M Y,J)fO 7 �,�-'AI f G
5a.Well Location: Phone#: ` 4l9— H Ys-g997 ft. ft. �!
e� ft. ft
.IJAvi� Net4► ..—e . ,i t,' I:rw.
Facility/Owner Name Facility ID#(if applicable) ft. ft
.e., Dr FIB+ tooJ.NC Dfs626 It, ft. MAY '3 S 024
Physical A City,and Zip ft. ft n. _ ;,?l,
As t, Q. 2L REMAUS , ,,F_....-esl .:.
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: �{3G6 1( I sq" N O$l° 30 ' 4Z " W e Ct-�✓Q-2 -' f�-
el
6.Is(are)the well(s):'permanent or ❑Temporary Signature of Certified Well Contractor Date 6'
By signing this form,I hereby cernfy that the well(s)was(were)constructed in accordance with .--
7.Is this a repair to an existing well: DYes or Kin 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Stmu/ards 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 remarks section or on the back of this form.
23.Site diagram or additional well details: C%
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 3
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. co
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drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 50Z k (ft.) ri-
For multiple wells list all depths ifd different(erample-3@200'and 2( 100� Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing:
J ) 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,we"+" <_
11.Borehole diameter: ‘ Cm.)Bit Off: Ss 910 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636 Z
12.Well construction method: -•�1 �`IR/y 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
13a.Yield(gpm) 3 Method of test Jam, Permit Program,1611 MSC,Raleigh,NC 27699-1611
70% hth oz Date Site Visited: 7* 1 • 2 3
13b.Disinfection type: Amount: Site Visited By: 1t
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
Price: S'.G-G ed A-1,-i #