GW1--03283_Well Construction - GW1_20240528

/�'1WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
4
1.Well Contractor Information:Ifo
'OCt '1�I It S •,54:WATER ZONES
Well Contractor Nr 1'e FROM TO _DESCRIPTION3.5-0 ft. 10 r , f fs % SL
f)5 70)-.6 SOOL gl�t ft / 61
61
NC Well Contractor Certification Number 15.:OUTER CASING(for mrilli cased w )GRLINER(if ap lieable)
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS 1 MATERIAL `�
ft. ft. in.
Company Name , ,l.I IC g A
fl :;16:'IIdlER CASING OR TUBING.(geothermal dosed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIG County,State Variance,etc) .I.' ft. 79 ft G,Or in. sag,.?-i a✓L
3.Well Use(check well use): ft. ft in. V�
r/�
it
Water Supply Well: RO�_ TO DIAMETER SLOT SIZE THICKNESS MATERIAL
['Agricultural ❑Municipal/Public ft ft in.
['Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) :18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: n ft. 9' ft got.d fv v.- &
❑Monitoring ❑Recovery q ft gy e ft �„I.��tt ./
Injection Well: 7 �u���
❑Aquifer Recharge .❑Groundwater Remediation
U-1.9 SAND/GRiAVILPACK(if applicable)
❑Aquifer Storage and Recovery ['Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD '
DAquifer Test ❑Stormwater Drainage ft ft _
['Experimental Technology ['Subsidence Control ft ft.
['Geothermal(Closed Loop) ['Tracer 20.DBILTIGLOG(attach addlttanal.sheets if.necessary)
FROM TO DESCRIPTION(color,hardness,soWroek type,grin size,etc.)
['Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) ® ft �� ft ! '
Date Well Started 4I- 2(o-Poly /� �J /+ I
4.Date Well(s)Completed: S-) - .W Wells A?1Q-020 1p 8 ft gyp:- /T)8A ,SC74- Grey 1Jer�•e id L.4,4Phone#:7oq- t S-g751 ft. ft. l- 1
5a.Well Location: �,t.$4 7Z.
ft ft
Facility/Owner Name / Facility ID#(if applicable)
joi" (I /VVVs4v1iV Dr Le.iv S ,
r,l �.) ft ft. ft
ft MAY :�, ��i24
Physical Address,City,and Zip 42514
f514 y
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �.
(if welll field,one lat/long is sufficient) 22.Certification: / �f ` j ��. ,,
w
6.Is(are)the well(s):, ermanent or ❑Temporary Si of well Contractor Date �'
By signing this form,I hereby certify that the well(s)was(were)completed in accordance with N
7.Is this a repair to an existing well: DYes or , io 1SA NCAC 02C.0100 or 15A NC1C 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 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 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary. .
drilled: 24.SUBMITTAL INSTRUCTIONS
i
9.Total well depth below land surface: (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells Iist all depths ifdifferent(example-3@200'and 2Q100)
at
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: /00 (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 co
If water level is above casing,use"+"
11.Borehole diameter: 6 (m,)Bit Off: 6,o90 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC) ry
Program,1636 MSC,Raleigh,NC 27699-1636 -p
12.Well construction method: G l P r b4"R f'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
y� Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: r^/8 t�l r
70% Date Site Visited: g - 1 - .11
13b.Disinfection type: hth Amount: eiX�•3 OZ Site Visited By: MA-14-
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
Price: