GW1--03582_Well Construction - GW1_20240613

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: ��
1.Well Contractor Information:
3C(r-i t 03'1c..AS 0.4.WATZB:ZONES 2:::...:..'. •
FROM TO DESCRIPTION
Well Contractor Name re i ►( A
� ft. 1 ft. ' awl "/ �Z �i I
3 4 J+ A ft. .l43O•ft //2 QPM
NC Well Contractor Certification Number
15l'OUTEIVCASING(foi`multi"ceied"wel i :OR'.LINEIt'Oa;"ilialile) :_
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL:
_ ft. ft in.
Company Name 7 y C/ /� /� _.
O ! 1S �V ?16 INNERGASING.OR':1'UIiING:(rot)ierm"al eloped=1o"0"1'. • :.,......
2.Well Construction Permit#: FROM TO DIAMEr eR THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Court',State, Variance,etc.) ,i 1 ft. !. 1 ft. V/_ 1/ in. 5DR �4
3.Well Use(check well use): ft. ft. in. —
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
❑Agricultural ❑Mu•• ipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) ec : ntial Water Supply(single) ft ft. in.
❑lndustrial/Commercial ❑Re i•icntial Water Supply(shared) '18s GROUT •
Cl Irrigation ❑Wel:i>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 R' 2 1 ft i4 k PI.+9 Po unre) it,A,og,
❑Monitoring ❑Recovery ft. ft.
Injection Well: —
ft. ft
['Aquifer Recharge ❑Groundwater Remediation
• i`19.SAND/GRAVE T:.P:AC&'.(ieiff'licable) ..`.-, . .
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD '
❑Aquifer Test ❑StormwaterDrainage ft. ft
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer 20:DRItii GI OG(atti'ch idditienial sheeti if necessary)
❑Geothermal(Heating/Cooling Return) ['Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock rock type grain size,etc)
Date Well Started $ )13l 0 ft. no ft 5 e,1
4.Date Well(s)Completed: S 301W Well iD#A4a- O 3 f 10 ft. /0,0 ft 'r n
�„94fone#:7Oy- 9,f3, 2789 ft. ft �7
Sa Well Location: ;— LL
ft. ft. t'�L l.t l..r t� + S
�c k �l3�ctw ABM Fwrh 70y-G16v771/
Facility/Owner Name Facilitym appli
cable) ft ft JUN 1 c 2024
'-"F-
ell Ik CrQ•k/vw6y id f"5��s4 ft. ft
Physical Address,City,and Zip .2�7 q}6� ft. ft. I r.for ri 4.ti£ 'I-c �" vi• I Uri:
W ' r ke,s — •21RF.MARLZS 414w{L.•i
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ----
(if well field,one lat/long is sufficient) 22.Certification:
36 '• ,s-'sa'1 N $i° 3 v 36 '' W
6.Is(are)the well(s): 'ermanent or ❑Temporary Signatur ofC ed ell ontractor 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 o 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 an explain the nature of the of this record has been provided to the well owner.
repair under#21 remarlm 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: 1 24.SUBMITTAL INSTRUCT"'IONS y�
9.Total well depth below land surface: I O DO (ft.) "1
For multiple wells list all depths if different(example-3@200'and 2©100') Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR), `o
10.Static water level below top of casing: co (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)
11.Borehole diameter: (in.)Bit Off: G•�3.3 Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: C1 cr f' Cb lAy 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to th
(Le.auger,rotary,cable,direct past etc.) �✓- county environmental health department of the county where installed
FOR WATER SUPPLY WELTS 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) 2 Method of test:
�� ��f -Z3 vQ
� /
Date Site Visited: -?f 2/Z y.Mb
13b.Disinfection type: 70% hth Amount: "7 0 OZ Site Visited By:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources ) Revised 6-6-2018
Price: