GW1--03587_Well Construction - GW1_20240613

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
/��J I_ L n
"I 4 T7 l vv bit)W Y1 pia,wnl zoNEs:i, ._:.,.
FROM TO DESCRIPTION
Well Contractor Name y 1 /7y� ft. / y( ft A b Cii y�A
�� ®;� ft. �Je'ft- ;o 1
NC Well Contractor Certification Number ';:15.'OIITZ•;IT CASING(fiiiiiiilti-"ca`sed LINER{irapticalile)
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL ,•�1
Company Name V 1641
c'3 7�j =;.6fINNEICCACING.ORxuBING_'(geVt.liermal'eloeed=Io'cli . , h/ �1
2.Well Construction Permit#: 3.
se FROM TO . DIAMETER THICKNESS MATERIAL �/�_ l
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) —L ( ft. 7 y ft. / ,'SJv in. a,;fly/! j f o c/ 1
ft. ft. �} O in. gJ 4) liryl �l '''A))
M 1
3.Well Use(check well use): V Q
:37 SC1tF . J
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUl'trblic ft in.. ------ '7' �- �-
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft X
/m.
❑IndustriallCommercial gesidential Water Supply(shared) .18?GItottD,:. ... •:
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT rut I
Non-Water Supply Well: C ft' •i %i ft'
24int
f` C-.4..s 6,,-;✓�-f, - Ve
❑Monitoring ❑Recovery I/,. ft —7 y ft .w Y./ 1: . L- Ri /0 24/ a, lU3
Injection Well: di T C.c s�w 9-
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation i
i`.19.SAND%GRAV.FS`:PACK(if applicable) ':.. JAI "r t.1-IS
❑Aquifer Storage and Recovery - ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD -
❑Aquifer Test ❑Stormwater Drainage ft.
ft /
❑Experimental Technology DSubsidence Control Z.4ft. /
❑Geothermal(Closed Loop) DTracer ':20.DRIY.LINGLOG(attach iddrtiOnal Meets if:necensaazp).'•: ::
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DFSQ2IPTICIN(color,hardness,sall/rock type grain sic etc.)
Date Wet Started 33 t- 9 Li /�I 0 ft G® ft .s
4.Date Well(s)Completed: ep—3414 Well ID#A4CSC"" 227 so ft o��e)'ft ,,o�'� i'° e))„ 6 pd 10 r 6,f.r
5a.Well Location: Phone#: $2 8.- ill- TSi II ft. ft
R {tom) ! ft. ft.
Fac
k z3 4 r(, I D �3(o J1A6 I.®ck .)eon ty/Owner Name *-.! Facility ID#(if applicable) ft f _ _ \`
ft. ft. .`vr..`�i... V ED
Physical Address,City,and Zip ft. ft 1
} 21711EmAl,�S.. .- -, ,•:::;_ J U N z0 4._ T 1)
Uys cc
County Parcel Identification No.(PIN) IriOr T,ihC` ""r-r ;rQ tJ,'I 3
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one'at/long is sufficient) 22.Certification: `
3 ‘' 10' 37.is N g 1' 3 ' 9 2L'/ W /9
ature of Certified Well Contractor Date
6.Is(are)the well(s): Xermanent or ❑Temporary (®
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 )1(No 15A NCAC 02C.0160 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 well owner. r a
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 FL-
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
9.Total well depth below land surface: 4t,•A (ft.)
For multiple wells list all depths if different(example-3Q200'mid 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),
10.Static water level below top of casing: 7�,y- (ft') Information Processing Urit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
6-Pic ? 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC) ro
11.Borehole diameter: (in.)Bit Off: Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:_ /q I r I a 4 a 1, 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) 3 0 Method of test: A 1 1
o Date Site Visited: 22 j1 r I/"2 yAOM
13b.Disinfection type: 7C�o hth Amount: 9,„),, OZ Site Visited By:
set, CoA}fi; -r -11- Z
Form GW-I North Carolina Department of Environmental Quality-D:vision of Water Resources Revised 6-6-2018
Price: