GW1--04344_Well Construction - GW1_20240722

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ffiL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Infor olio
r.14:WATER PNES
i/ FROM DESCRIPTION
WellConnacWrN a /� ft. !m--I!
ft
1
J G� ZOO n. ft 160
NC well Contractor Certification Number 15.OUTE9 CASING for miilti4ased'Welli OR LINER(if" cable;
Yadkin Well Company, Inc. FROM ToI numit R I MCK"M MATERIAL
Company Name 7 r 3- C Aso ft
Qgvt C 3' :16:MNERCAMGORTIMING eothermalclosed-lab' '
2.Well Construction Permit#: 4 FROM To DIAMETt�t TE11C¢NFSS MATERL&L
List all appheab/e well construcion permitr rLe.WC,County,State,Variance,etc.) ft. TO
in
3.Well Use(check well use): ft. ft in
" -
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) NGideutial Water Supply(single) ft. ft. in LA
❑Iadustrial/Commercial ❑Residential Water Supply(shared) .18.GROUT
01r.rigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft 7 t 7
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft --
❑Aquifer Recharge ❑Groundwater Remediation (
19.SAND/GRAVEL:PACK`rf a 1ic-M- -- IL
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDminage ft. ft G
❑Experimental Technology ❑Subsidence Control tr• ft Ito';
❑Geothermal(Closed Loop) ❑Tracer `-20:DR1�7 IVG'LOG attacb`addi$'o`da1 rle�'"
❑Geothermal eaten Coo ❑Otber lain under#21 Remarks) FROM To DESOUPTIox color,hardness,soilhoek typN grzin dze,eta
Date Well Started v s. i rt C��
4.Date Well(s)Completed: 4J L- `1 Well ID## AQ—0Q� 1 n' 4 rt a t) �
Sa.Well Location: Phone#:3Z-(?71-7636 ft. 3U ft R�
33(,-• -733-vk3 1� I ft 4 Gi "
Q vie
Facility/06ner Name Facilit��yeeID#(if applicable) L Z R
(Ze zyl) � /'xoC,l�(J lriue Zti t n k 2ft "SO r.06L.,ILe
Physical Address,City,and Zip `4`3 ft 5 K 2 ft S V f j l
QW/d zi ItEtlfAxlCs.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degreea/minutes/seconds or decimal degrees: 17
(if well field,one lat/long is sufficient) 22.Cer'Pfed
6.Is(are)the well(s): Mermanent• or ❑Temporary Si 12Cf-.7100
well Contractor Date
-/ llyun ,I hereby certify that the well(s) (were)constructed bt accordance with
7.Is this a repair to an eristing well: ❑Yes or W. JSd NCA or 15A NCAC 01C.0100 Well Construction Standards and rhos 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#11 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: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ` L (fk)
For multiple wells lint all depths ifdffsrent(sample-3@200'mud 1@100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If xnrer level is above casing,use"+'
11.Borehole diameter: Cm.)git Off. 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
LL Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Ad., #pTary 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.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 D CCPCUA
Perm
it Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) . Method of test: Cl a r C/
., Date Site Visited:1 D•-(J
13b.Disinfection type: 70 o�o hth Amount: OZ Site Visited By: n,316
G-v
Form GW-1 North Carolina Department of Envircamental Quality-Division of Water Resources Revised 6-6-2018
Price: 10