GW1--03278_Well Construction - GW1_20240528

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor I formation:
l (/ 1.-.; (/ 04.WATER ZONESftk
FROM TO DESCRIPTION
Well Con actorName TB lft 7? . ' OM .)
3 ?- -4"ft. Li Csft. i q I 1 s
NC Well Contractor Certification Number 15.OTHER CASING(for mslti=ca'sed s)OR LINER(trip' caible):.;,:
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft in.
Company Name (7•
q){'�/'// :16.INNER CASING OR TUBING(Rehthertaal doaedTobp)'.�
2.Well Construction Permit#: '[ C(L� FROM TO " DIAMETER THICKNESS MATERIAL O
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) �t" fry ft. S,I,,r in. S(J e 2' 0 v
3.Well Use(check well use): iL n in. 1 f'�i f V
Water Supply Well: FRO�� TO DIAMETER. SLOT SIZE -THICKNESS MATERIAL
['Agricultural ❑M cipal/Public ft, ft. to
['Geothermal(Heating/Cooling Supply) lliResidential Water Supply(single) ft. ft M.
❑lndusbial/Commercial ❑Residential Water Supply(shared)• f.18:GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Lift. 3 ft 6t14-c0sit. flpS eQWrtd4
OMonitoring ❑Recovery ft. ft.
Injection Well: '
ft. ft.
['Aquifer Recharge ❑Groundwater Remediation
119.SAND/GRAVEL PACIgif'ij plieible):
['Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Flcperimental Technology 0 Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ['Tracer 20.DRILL1NGLOG(attach additional sheets ifnecessary)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM ft•
TO ft DES N(color,hardness solllroek type grata s ze etc)
Date Well Started L */ VI `�� V 5- ft
.ii
4.Date Well(s)Completed: i"� Well ID# O�I 3}eft. ' ft 5/,,,it..
5a.Well Location: Phone#: 334 d 7 7 4,V',?el:ft.
V ('-ft sae j'(i` eiic ) s' t, co�- ft. ,M.f� 1 v%all t
ft. ft
Facility/owwnn�erNajme till'
�j, v
Facility ID#(if applicable) 11ft. ft. E
ill
ei AMC
Physical Address,City,and Zip ft ft ,y AY 's S 2024
A5 )! L 21:REMARKS.
County / f' Parcel Identification No.(PIN) E{,,;:r ' .
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: L'' `(if well field,one lat/long is sufficient) 22.Certification:
3 6 �.v, 56•Zrl71 V 3 �4'r� W , G
['Temporary
of Certified Well Contractor Date
6.Is(are)the well(s): *Permanent or
By signing this form,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: [Wes or go ISA NCAC 02C.0100 or ISA 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 remarks section pr on the back of this form.
23.Site diagram or additional well details: t"'
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 nee/ed. 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: 5-0 (ft) 1.
For multiple wells list all depths if different(example-3@200'and 2Q100) Submit this GW-1 within 30 days of well completion per the following: .-IN`
10.Static water level below top of casing: SO 24a. For All Wells: Original form to Division of Water Resources (DWR),
( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 ,41‘
If water level is above casing,use"+"
11.Borehole diameter: 6 (in,)Bit Off: t. O J 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636 T'
12.Well construction method: 071-4
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,
rNC 27699-1611
13a.Yield(gpm) e)O Method of test: ai'r Date Site Visited: l a�-.2 -�.3
13b.Disinfection type: 70% huh Amount: 3 ' OZ Site Visited By: b
JM
J- I+. 3oi`- Sol` Dry( fd
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018