GW1--04301_Well Construction - GW1_20240722

vtTELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: „C j\i'a
1.Well Contractor Information: I i'
-leery Wr1�- '`a3 4 WAT zi zoNl;S b I
FROM TO DESCRIPTION
Well Contractor Name
• 2-T ft. 2 30 ft 1 Carr k''''')
at-1J S-D A ft. .,' ft
NC Well Cootractor Certification Number 15.`OU,. ) p )N.1{CASlNG(fozm"ulii=cased"weils:ORL] EL(ifalIda`lls)p '
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
f 13-.16�Il\NERCASING:OR;1'LBING(Qeatlieimar closed=loopf' .
2.Well Construction Permit#: I$ FROM TO DIAMETER THICKNESS MATERIAL _.Pi'
List all applicable well construction permits(i.e.UIC,Cownty,State, Variance,etc) .4 I ft. 93 ft /V IA/ in. spR 7 pVL
3.Well Use(check well use): ft. 7 ft. in.
Water Supply Well: O I TO DIAMETER SLOT SIZE •THICKNESS MATERIALr
❑Agricultural ❑Municipal/Public ft. ft In. f'®
❑Geothermal(Eleating/Cooling Supply) ❑Residential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 1'18"GItOUT.
❑hrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: e) ft. a 3 ft Wolf Plus Pe u cr.! I I1 6%55
DMonitoring ❑Recovery ft. ft.
Injection Well: — —
ft. ft
❑Aquifer Recharge ❑Groundwater Remediation
1'19.SANDIG_R'AvK'-P.ACK(IEsppli'cable) 'I
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft.
❑Experimental Technology ❑Subsidence Control ft. f.
❑Geothermal(Closed Loop) DTracer 20.DRI LIN—GIOG(itiiicliidditionrl'slieetiifneci iePy)'1 i ::.: .:, ;:; :': .
❑Geothe mal(Heating/Cooling etum)) 0 Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,salllroek type grain size etc.)
Date Well Started C. 110�3`1 O ft. 83 ft sot I
4.Date Well(s)Completed:(f 1 I I.34 Well ID# AA 0- P39 83 ft. 1412 ft /►t,t
sa.Well Location: Phone#: 33G-. 17— I�i JO ft. ft la
.5okrt 4- An9'. Snpler ft. ft �-• -. .k., f 7-
^_ -a
Facility/Owner Name Facility ID#(if applicable)
fr. ft `a,�•.r-� yf 1+ s
P7 rn. ddw Ln. tomes{ S e•Cref-S 00110 ft. ft • JULL 20Z4
Physical Address,City,and Zip ft ft. c ►^r^ nil
N Pg/Dei� ':21 F2RMARYCR Iisr i �.Y �.-
01
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:
31°° ao' 49'' N Si° at; 34 in W 4 Li.) . 1 oy
‘ik6.Is(are the well(s):Oermanent or ❑Temporary Signatule of C ed Well Contractor Date
By signing this forte,I hereby cerdfy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or JIo 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 421 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: 1 24.SUBMITTAL INSTRUCTIONS
•
9.Total well depth below land surface: LI 70 (ft.)
For multiple wells list all depths if different(example-3@200'and 2Qa 100) Submit this GW-1 within 30 days of well completion per the following:
�0 (ft') 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617 6+
If water level is above casing,use"+„
11.Borehole diameter: IP (in.)Bit Off: 6.04 I 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11 Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: a I< CO to 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 WELT S ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) I Method of test:
iris 4J r Permit Program,1611 MSC,Raleigh,NC 27699-1611
70% hth Date Site Visited: to 1 to I 2 Y
c:i
13b.Disinfection type: Amount: !G OZ' Site Visited By: (11,8
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
Price: