GW1--03279_Well Construction - GW1_20240528

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: ((�� 0
leer-J WaTilri OS 04.WATERZONES .•
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Well Contractor Name FROM TO DESCRIPTION
.# ?4 5 A ft. /010 ft 3 66vi
ft. ft. in
NC Well Contractor Certification Number
15.OUTER CASING(far mtiltVeiised'wells)OR VIER(if ap livable)`
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL,
`'
ft. ft in.
Company Name
] t� 16 INNER CASING OR TI BING(geother-iiia1 closed-loop)
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2.Well Construction Permit#: / C�[D-.3 FROM TO DIAMETER THICKNESS MATERIAL ..._P.
List all applicable well construction permits I e.UIC,County,State,Variance,etc.) 1/R. 5I ft / S/e in. . lI s• Gel v
3.Well Use(check well use): ! ft. ft. {/ in. I
Water Supply Well: ' 'Wit
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft tn.
❑Geothermal(Heating/Cooling Supply) 1eesidential Water Supply(single) ft. ft. in. n'
❑industrial/Commercial ❑Residential Water Supply(shared) :18.GROVE s
❑lmgation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT j
Non-Water Supply Well: O ft 3 ft NJ' 1105 Pound 3 --'
OMonitoring ❑Recovery 3 ft. 24 ft. pwmk 6r. b Pu1N 41
Injection Well: ft. ft.
❑Aquifer•Recharge ❑Groundwater Remediation
i 19.SAND/GRAVELPACK(if applicable) ;'
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHODos
❑Aquifer Test ❑StormwaterDrainage ft ft or
❑Experimental Technology ❑Subsidence Control ft. ft
ar
rao
OGeothermal(Closed Loop) OTracer 20.DRI 'SNGLOG(attcbadditfonal'Sheetsifnecrssaryy) __ '
PROM TO l DESCRIPTION(color,hardness,sail/rock type,grain she,etc.)
❑Geothermal(Heating/Cooling Ret�) ❑Other(explain under#21 Remarks) ft ft.
Date Well Started N 116 171 Q G�y U 12 ,S4i/
4.Date Well(s)Completed: 1 jI f St• WeU ID# / /_� 1 / I ? ft 1 G ft. 6 ear,. k
5a.Well Location: Phone#: y,0 - 56- W 21. ft. 3s ft 81.O10 h i.Ckk
Kt.i`14 3"1-1),es- 5•-t P- 06-#(/r0 3g R 7O it G eon,to
Facility/Owner Name 1FacilityID4(ifapplicable) 7t0 ft- VS ft- QrOy/a�► IGOGk
filPinelDratir. -Y'dee Meivn Tcir),Todd/Ar Z8g4 PS ft. 144/7. GCanes
Physical Address,City,and Zip ft. it
A } Pr,' 2LRF.MARXS
-s-A� "A c=e7 c 4.- _
County Parcel Itlrnti ration No.(PIN) i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well Eeld,one lat/long is sufficient)
22.Certification: MAY 2, S 2024
? 6 1W. Lf/// N 8 ) 3(, ie17 .37 w
6.Is(are)the well(s):, ermanent or OTemporary Signs a of C ed well Contractor i ' ',,,;Date
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 PiCio ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy es),
If this is a repair,fill out blown well construction information and explain the nature of the of this record has been provided to the well owner. .c
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
const ruction,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.
drilled: 1 24.SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: , -7 'U 7 3 (ft.) Submit this GW-1 within 30 days of well completionper the following:
For multiple wells list all depths if different(example-3@200'and 2Q100') y g
+� 24a. For All Wells: Original form to Division of Water Resources (DWR), t�10.Static water level below top of casing: I tit)
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use +•' -.III'
11.Borehole diameter: (tn.)Blt Off: 5-s 7 7 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC) �l
Program,1636 MSC,Raleigh,NC 27699-1636 t 4"
12.Well construction method: Y 1) to Ly 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the -Y
(ie.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
3Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: �1 /" .
70% hth Date Site Visited: 3 -1 ff '3
13b.Disinfection type: Amount: 34 oz Site Visited By: i/ie
Form(iW-1 North Carolina DepartmentypfEnvironmental Quality-Division of Water Resources Revised 6-6-2018 /
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