GW1--03579_Well Construction - GW1_20240613

'ALL CONSTRUCTION RECORD (GW-1) ' For Internal Use Only:
1.Well Contractor Information:
i c a p I V k k:.3 R 4:WATE 'ZONES_ (ra
Well Contractor NaID it.FROM TO ^1t DESCRIPTION ,,�(�
NC Well Contractor Certification Number
'f 1STOU'IWCASING'(for`mniti=c'a`setlweftlyOR'LINEB OCiti licable).::,;
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS 1 MATERIAL —
Ry
ft. ft in.
Company Name �."
s P�•
I
f� . `(Z :.:if -clo'edloop)`
2.Well Construction Permit#: (J ^J FROM TO . DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) � / ft Cil ft 6./_� in. s Y�F•,a f u,, 3
3.Well Use(check well use): ft. ft in.
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL a,
['Agricultural ❑Municipal/Public ft. ft. in. Lli
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft ft in.
['Industrial/Commercial DResidential Water Supply(shared) '1$C`GHOUT:.'.
['Irrigation ['Wells>100,000 GPD FROM TO MATERL°L EMPLACEMENT METHOD&AMOUNT
Nan-Water Supply Well: D ft. y • ft t4f-di'1,c u tJ
[Monitoring ❑Recovery /f °ft. 27,i ft. RQvr5d,rC►_ d
Injection Well: '7 rlefel
ft. ft V t
['Aquifer Recharge ❑Groundwater Remediation
1'19.SAND%GRAY ..ACK(if;nliilli lile) .':..'1- -
❑Aquifer Storage and Recovery ['Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD -['Aquifer Test ❑StorrnwaterDrainage ft. ft.
[Experimental Technology ['Subsidence Control ft. ft.
['Geothermal(Closed Loop) ❑Tracer '20.DRICIINGZOG(attach'idditialial Sheets if:nec"e§saiy) ,.
❑Geothermal(Heating/CoolingRcturn) DOther(explain under#21 Remarks) FROM ft TO t ft DESCRIPTION(color,hardness,sail/rock type,grain size,etc.)
Date Well Started 5 3•,)0y ^QPy / ft �� ft •��� ���� �r glen.4.Date Well(s)Completed: s^ r3 )c)1 Well ID# 77� %a /*ee Jp 7C� 3c71R- `/'E'y
`` 5a.Well Location: Phone#:336.. ryg y �� S. A Oft. yeaa ft pi, ,f 0_ 4 ,401 . /
�n5^i.. 4 AMGn`tt Gr©le+ ft. ft. _�.,_ - —..
Facility/Owner Name Facility 7D#(if applicable) ft. ft i v..L. L. V !.�,i
i 0 q $A gooN, lra,'l Puri ;X6GS" ft. ft JUN 1 ; ?024
Physical Address,City,and Zip ft. ft
, /, '..21'.7'RFMARICS.. .!. ... ir,4tg r.i,UZ aii1"-,r :;/V may
b
I i A cis 1:P Ca IG-tip
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:
3 ° Icy' 6 " N E l 19 ' 13''' W C� i s )3
6.Is(are)the well(s): Permanent or ❑Temporary Sid of C�.ed Well Contractor 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 .ko 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 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-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
chilled: I 24.SUBMITTAL INSTRUU1'IONS
9.Total well depth below land surface: `'3 (ft.) Submit this GW-1 within 30 days o f well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2Q100')
10.Static water level below top of casing: ?C "? (ft.) 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,use"+" W
/ 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.13orehoIe diameter: (in.)Blt Off: (d•,D'y. Program,1636 MSC,Raleigh,NC 27599-1636 r
p
12.Well construction method: lit,," /d 7 G/7 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the T'
(he.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) 1 %2—, Method of test: /'/p 4ie Permit Program,1611 MSC,Raleigh,NC 27699-1611
o O Date Site Visited: 9-- 2 7- Z
13b.Disinfection type: 70�' hth Amount: /T.S OZ Site Visited By: .Mi
Form GW-1 North Carolina Department of Envirorunental Quality-Division of Water Resources Revised 6-6-2018
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