GW1--03580_Well Construction - GW1_20240613

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: cbI
y Lj 1 r 1UI •`S `14.WATER ZONES . .
Well Contractor ame FROM TO DESCRIPTION e.,V1 j1
r°i
ft. ft c„c
NC Well Contractor Certification Number
15.OUTER CASING(for multicosed walla)OR LINER(if in liealile)'
Yadkin Well Company, Inc. FROM TO DLLMETER TEUCxNFss MwtlrRIAL
ft. ft. in.
Company Name / /f
D Art j . — 0 5 3 L� FROM ER CASING OR TURING.(p[eothetmal closed-loop)
2.Well Construction ermit#: V FROM TO -DL '[�x THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIC,County,State, Variance,etc.) l ft S 9 ft. /*.)�s in. SoJ 3 i �—
3.Well Use(check well use): j ft. ft 4 — in. /`
Water Supply Well: l 's'
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public I ft ft. ir..
ElGeothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. it
❑IndustriallCotnmercial ❑Residential Water Supply(shared) ;18:GROUT
Oh-ligation ❑Wells>100,000 GPD -FROM TO MATERIAL EMPLACEMENT METHOD Si AMOUNT
Non-Water Supply Well: U ft. _doft. j'. Cl'121 ,gs'1 feI
❑Monitoring ❑Recovery ft. ft �'"
Injection Well: —
ft. ft.
DAquifer Recharge ❑Groundwater Remediation
i 19.SAND/GRAVEL PACK(if applir.'able)'.
DAquifer 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:DRY1,7;ITIGLOG(attach'idditioriilsieetsiinecessary)
DGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil Tonic type,grain size etc.)
Date Well Started 5,a.1 -•ioz'I ft ��`ft .5— ►
4.Date Well(s)Completed: S a}26)1 Well 1D ys ft 1 " ft riled t J 1 S E4t tJh:`le
Sa Well Location: Phone#: !o` 31- (,R® ft. ft. P Iir4e ReCok 5
A pilr dt 7L ft. ft. , ,e `
Facility/ty/ Name Facility ID#(if applicable) ft ft �� �►
,.�l.7 fUrIC.A�NCe W cDg9 ft. ft. JUN 1 s 1024 "
6J'
Physical Address,A 4jj CRy,and Zip ft. ft. ...0
/ 21:REMARKS'
Ir ' L ar :1 4 .y Jr.. �—
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:(if well field,one latllong is sufficient) 22.Certification:
6.Is(are)the well(s): Permanent or ❑Temporary SQ
fC d 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 ANo 15A NCAC 02C.0100 or 1SA 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 forth. <.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-his needed. Indicate TOTAL NUMBER of wells (a.dd'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBNIITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 4 (ft.) Submit this GW-1 within 30 days of well completion per the following: �j�
For multiple wells list all depths if different(example-3(41200'and 2©100') (`-'
s-e
? 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below tcp of casing: (ft•) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)--3,C
11.Borehole diameter: (in.)Blt/�Off: �o/Oy Program,1636 MSC,Raleigh,NC 2.7699-1636
12.Well construction method: e/g`. R`40 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
Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: /",c,7/4 01
0 - Date Site Visited: 9 9 -�_4
13b.Disinfection type: 7O�o hth Amount: /1�++ OZ Site Visited By: 1./ 5
Farm GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018