GW1--03282_Well Construction - GW1_20240528

V)
. \ ELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: v
1.Well Contractor Information: $T
4 1v,/ �i ka t1R FROM WATKRZONES r�'u
FR
Well Contractor Name ii TO DESCRIPTION
��o co ft. 611 ft (wsC . " Close-` #-s.—)
ft. / ft
N ell Contractor Certification Number 15."OIITER"LASING'ffiiii mirlfi;W ed:welli :ORLINFIC(if.`ap'licabl
Yadkin Well Company, Inc. FROM TO DIAMETER TfficKNFSS MATERIAL
Company Name `- jft G h ft 6 4 O tin. �J !2 1 k(-
;16_INNER'CASING:01t,ruHING.t iithesmil doled=1iiep) ..: . .
2.Well Construction Permit#: % FROM To D a THICKNESS 7AL
List all applicable well construction permits(i.e.VIC,County,State, Variance,etc) ft, ft. in
3.Well Use(check well use): ft. `/ ft in.
Water Supply Well: - •
PP Y FRO TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural ❑Municipal/Public ft. ft / Q
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft in. [ (
❑Industrial/Commercial /❑„Residential Water Supply(shared) x - —
PP
1B:GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT OD&AMOUNT
Non-Water Supply Well: D ft. ?.� ft. ea 1�7.( /--_ via _, ! Y f,
[Monitoring ❑Recovery ft ! ft 1Jf'L�/ �' 1
Injection Well:
ft. it A
:Aquifer Recharge ❑Groundwater Remediation 1..19 SAND)GRAVFSrBACI((if.`ipplicabTe)":..
[Aquifer Storage and Recovery 0 Salinity Barrier FROM TO mIA ..❑Aquifer Test ❑Stormwater Drainage ft• ft ..,
❑Experimental Technology ❑Subsidence Control ft, ft
❑Geothermal(ClosedLoop) ❑Tracer .20.DRIl1fit TOG(ittechiaditioruirshee /MENTMETHOI)
,` : :.;`: ::`.:•.
❑Geothermal(Heating/Cooling Return) ['Other(explain under#21 Remarks) FRo TO DESCRIPTION(color,hardness,sdllrock type grin sae,etc)
i ft. I y ft 0/! .rei'.
Date Well Started �- Y 2 ( ` ,/
4.Date Well(s)Completed:,s"q 2(( Well ID# Q�/ ft. T�2 ft I. pi_ rrL� Sand- 3D
Sa.Well Location: Phone#:q J "4 Sl=jYglictt• TI to ft. kl1v4 Mk- rOIe -
6 4 k 4/ i'et V,'O, ` / J Gh, e A., to ft. G e 2fte„,,,,., el
Facility/Owner Name F ty ID#(if }�.ab�e),44 fr 9?Lft. a(/f..Jr
-
A.,o t �►`� G/GS,'Ai/ ce PL L ft. ft.
Physical Address,City,and Zip Cf ori,06 A it,i f ft. ft 0
�f !i2172F.MARl'CS P,N/ � ::
(1.County Parcel Identification No.(PIN) r " '
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: S
(if well field,one lat/long is sufficient) 22.Certification: MAY r+ 2024
3G 2 ? sllN _l S: 6 2(L W S 5-.'t-2y
6.Is(are)the well(s): [ ermanent or ❑Temporary Signature of Ccttifie Well ntractor 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 ,Io 15A 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 of this record has been provided to the wall owner.
repair under#21 remarks section or on the back of this farm.
23.Site diagram or additional well details: •6*--
8.For GeoprobelDPT 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.
drilled: Ib 24.SUBMITTAL INSTRUCTIONS
9. Total well depth below land surface: V 2 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2Q100)
24a. For All Wells: Original form to Division of Water Resources (DWR), R.,,
10.Static water level below top of casing: tie 6 (ft') Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: (in.)Blt Off: Co. b'G 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: r d / 11- 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 01
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) v Method of test: 4.r r �
° Date Site Visited: 3—q _Z if l e
13b.Disinfection type: 70/0 hth Amount: OZ Site Visited By: V
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018