GW1--04298_Well Construction - GW1_20240722

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: -.{
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1.Well Contractor Information: i/ -
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We1lContractorName FROM TO . ' DESCRIPTION ��
• 7� ft 71 ft .s';�.h
3 0 3 6 A E.
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NC Well Contractor Certification Number 1 'OUTEy:CAS1NG.(fnimulli"cssed'vr :OR NER::(ifap"liestile'TA
Yadkin Well Company, Inc. FROM TO DIAMETER TffiCICMESS MCTERIaL
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Company Name `r CAS GIL( ORQBILTG(geotHemalcloied3oo '
2.Well Construction Permit#: I J �Fi / FROM TO DIAMETER THICKNESS _ MATERIALList all applicable well construction permits(i.e.UIC,Comity,State,Variance,etc.) + I ft
• yg (�ft Al in. .SD/�.e'.2/ AC
3.Well Use(check well use): ft ft in
Water Supply well: z37: CR ..: :"::,_.:'•.:.: :',:.., s3's-•.:::;... ,
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipa]IPublic ft. ft in.
❑Geothermal(Heating/Cooling Supply) Lesidential Water Supply(fie) in /
❑Industrial/Commercial ❑Residential Water Supply(shared) 0.8?GR6UT::
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. al ft B f„1-o,�,),t G (i✓®.I 6,-,v/it ,' bar
[Monitoring ❑Recovery ft ft
Injection Well:
ft. ft.
DAquifer Recharge ❑Groundwater Remediation 419.
_
❑
0 Aquifer Storage and Recoveiy Salinity Barrier FROM BAND/GItT� ACKC MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage Xft �
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer ';20:DRI1VUINGI,OG(ittaeli idditbidarilieeti if necessary).a',< :I,,..;;........ ...
FROM TO DESCRIPTION(color,hardness,sal/rock type,grain size,ete) ��
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
Date Well Started 6 i 7- ?'/ ^^dd/� /�/ o it t1.r ft 4)1/ C
4.Date Well(s)Completed: 6- I7-.91 Well ID#!'4/T A- / 2- /X' yid ft 11.44./, e G4 /VL.tri"o n t,
5a.Well Location: Phone#: 3 36-I167-71,it yv ft• i b.( ft C9rc�,,'�'t/
1R. S+tosoh - (30:kit, ft. ft
Facility/Owner Name Facility IC*(if applicable) ...0
Ri'vtr L,1 W 'St 1,So',t IV(, ft ft JUL 1 ( 2024
Physical Address,
City,and Zip .2g694 t ft -.
l//e..l e./ i 21 7ks::: .... ,IC,f4 `'.c'Osk AQ` L '-.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one 1at/long is sufficient) 22.Certification:
. 36 e 1 g.i rjt, N CV .,J,/ lid
W
V 6- /7- ay
6.Is(are)the well(s): f'ermanent or OTemporary Si o 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: DYes or io 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 GeoprobelDPT 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 Over'in Remarks Box).You may also attach additional pages if necessary. (�'
drilled: / 24.SUBMITTAL INSTRUCTIONS
/
9.Total well depth below land surface: / (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q2000'V'and 2(§100) SU
10.Static water level below top of casing: / (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level it above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
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iv 24b.For Injection-Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: C Cm.)Blt Off: 6 r 3 2 Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Gi i r Y b fade 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
13a.Yield(gpm) 420
Method of test: / 4/. Permit Program,1611 MSC,Raleigh,NC 7699-1611
o Date Site Visited: l./- /' y
. 13b.Disinfection type: 70�0 hth Amount: 1/ OZ Site Visited By: ,N/Q
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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