GW1--04355_Well Construction - GW1_20240722

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: _l
1.Well Contractor Information: "4
SC(cki t/ lt..ke"S C.14.WATER ZONES 6
FROM TO DESCRIPTION
Well Contractor Name
y ft. 350 ft. 30 cf.,J A ft ft. P
NC Well Contractor Certification Number 15.OUTER CASING(for midti=eased•we113)OR LINER(if ip livable)
Yadkin Well Company, Inc. FROM ft. TO ft DIAMETER in. THICKNESS
MATERIAL 1
Ln
Company Name
r 16.INNER CASING OR TUBING.(geotLerival rlosed4n'op)':
2.Well Construction Permit#: 7 FROM TO , DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Ie.UIC,County,State,Variance,etc.) ;, I 8. /Q 1 ft o lik In. SDap71 p V C.
3.Well Use(check well use): ft. ft in.
175 .
Water Supply Well: FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
OAgricultural OMunicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Mtesidential Water Supply(single) ft ft in. •
❑Industria]lCommercial ❑Residential Water Supply(shared) 19.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 3 ft gale PIvs (o V re,d 3 ba s'
❑Monitoring ❑Recovery 3 ft. .'Y ft ?.sck Gr Ja* (pV a 9 1S Sf
Injection Well: ft. ft
DAquifer Recharge .❑Groundwater Remediation
i 19.SAND/GRAVXUPACIC(if spplicible): •
❑Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD -
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 29:DRiU,RVGLOG(iitfuti additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soltlroak type,grain she,etc.)
0 Geothermal(Heating/Cooling R 0 Other(explain under#21 Remarks)Date Well Started "7111 1.21 //�� a ® ft. 4D ft. SC. ; 1
4.Date Well(s)Completed: -11L 1 .1 icy Well m#AA a_ ^ 7 ) 4, ft" 3u; ft 6 rb,f1 i 4
Phone#: 704 SO7-4138 ft. ft
5a.Well Location: ft ft C
Cl,r; s Ferrel IP
Facility/Owner Name Facility ID#(if applicable) ft ft F. ;. ,viz:'A Ti
ty s 'LI !f+
V; l�4. i. P;.n e, .Dr SL°thuion }X n JUL 2 2 2024
Physical Address,City, dZip alto
2L'•REMARKS: int '4 :i ,
Jkg g
County Parcel Identification No.(PIN) DiskOr
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
36° 03s ' 71. N gI`' 079 425" w V`S 7(t2 f ;4
6.Is(are)the well(s):Xeranent or ❑Temporary sig. f C well Contractor Date
m
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ANo 15A 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 Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
You may use the back of this page to provide additional well constructit i 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: \ i 24.SUBMITTAL INSTRUCTIONS .
9.Total well depth below land surface: �7 (ft") Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3(a)200'and 2®100') 1
24a. Far 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"+"
11.Borehole diameter: 6 cm.)Bit Off: C.. ' 24b.Program For I63njection6MSC Wells:Raleigh CopyC to DWR,Underground Injection Control(IUC) ia)
,1 , ,N 27699 1636
12.Well construction method: di i r ro#d/'r - - 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,C4UA
'
Method of test: �'S Air Permit Program,1611 MSC,Raleigh,NC 27699-1611 `i
13a.Yield(gpm) 3 0 :
70% Date Site Visited: `I - II-23
13b.Disinfection type: hth Amount: ' OZ Site Visited By: f$4 Q
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources ti,:
Price: i . , . _ i r