GW1--04351_Well Construction - GW1_20240722

DWELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
J �1C:C� �Iv1r• 014`.WA1Z{!'ZONES
Well Contractor NaA
FROM TO DESCRIPTION
�!y ft. ft
ft
NC Well Contractor Certification Number 15.'OUTFACASING(ffi"r1ii1iltP a"sedweIIs' /�
Yadkin Well Company, Inc. FROM To DIAMETER, TIi1CKNESS MATERL�L C i
Company Name
:16sINNF.R? G:OR' G;'"eothermal dosedloo :.:+,.:.- .:. .
2.Well Construction Permit#: / 3 FROM TO DIAMETER TMCICNFSS MATERIAL
List all applicable well construction perniits(.e.WC,County,State,Yariance,etc) t ft. S" It.
/_ vo in- t /t1d ✓
3.Well Use(check well use): ft. ft irr.
Water Supply Well: FERpry TO DIAMETER SLOT SIZE TlriCrCNESs, MATERIAL
❑Agricultural ❑Municipal/Public 'g - In.
❑Geothermal(Heating/Cooling Supply) '(Residential Water Supply(single) ft ft. ln.
❑Industrial/Commercial ❑Rnsidential Water Supply(shared) :187GROUT
❑Irrigation ❑Wells>100,000GPD FROM To MATERIALrr EMPLACEM NMETHOD&AMOUNT
Non-Water Supply Well: ft. �0 ft. ,Pr - 'h` ;t!g1
❑Monitoring ❑Recovery ft. ft
Injection Well:
ft. ft
❑Aquifer Recharge ❑Groundwater Remediation
j 19.SAND/ •SLITP a"ble " -,•::: >.: ,J
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPIa 7MLrNTMETHOD
❑Aquifer Test ❑Stormwater Drainage y
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer 10:1)RI IINGI,OG ittiell iddithinalihietiifnecessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,sell/rock a min size,etc
Date Well Started 5- //)j//.. ) 7 n fc. Yt
4.Date Wells)Completed: t o Ie( Well ID#•4�-f Ui1�G L L e Q ft' s�C ft
5a.Well Location: Phone#: /151 - 3 Uf J - ?"77 5-#/Oft• 7.X3'ft z4.1 1AW
,�` 7,13 ft.
SG, VV/l(,ICiM� 3 ft. _
Facility�/OOwn/er/Name (� n Facility ID#(if applicable)
1 ( !(����/,ft /40 ' /1� '
`6r tLk, RJ LrL.,6' d�6f'� G'TV ft 'D ft- 1 l�i'� ✓�i�t �o
Physical Address,City,and Zip I6o -ft. 01 ( ft.
Ca Id V-L�� 21:�:17Fhf'iYRp'kR
County Parcel Identification No.(PIN) CKkI L C .16 v q0t)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ©'
(ifwell field,one Iat/long is suffidItt) 22.Certification: i
360 3 N �s ►� 30 ' -W
6.Is(are)the well(s):Xpermanent or ❑Temporary S arr,of ed Well Contractor
By signing this form,I hereby terrify that the well(s)was rwere)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or )11�0 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a copy
If this is a repair,fill out blown 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 farm.
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 necess_iy.
drilled: l ! 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1 ,J (ft.)
For multiple wells list all depths ifdifferent(example-3Q200'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),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
e . •.
<N�p 24b.For Injection Wells: Copy to DWR,Underground Injection Control(ICIC)
11.Borehole diameter: (in.)Bit Off: s V program,1636 MSC,Raleigh NC 27699-1636
12.Well construction method: J / "f'"
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 O Y: � 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCU
r,w p�� Permit Program,1611Raleigh,NC 27699-1611
13a.Yield(gpm) t/1 lfy�� Method of test:� v,;r
o Date Site Visited: .>2
70/o hth 4� oZ Site Visited B
13b.Disinfection type: Amount: y:_
Form GW-1 North Carolina Department of Envirorunental Quality-Division of Water Resources Revised 6-6-2018
Price: