GW1--04357_Well Construction - GW1_20240722

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractorn�A Information:
L O(j )374,1 .J ('.14.WATER ZONES
Well Contractor Hine FROSL TO DESCRIPTION
4 7 ft. /u r ft see,- c!/s--'1 ,t /.d r
,
ft 7 ft. ,
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells OR
le) 473
Yadkin Well Company, Inc. ) IICKNEINER(Sfap[MATE
FROM TO DIAMETER THICKNESS N2ATERIAI, - .3
ft. ft in. I �✓
Company Name 16.INNER CASING OR 1'uBING
L a ` , i‘l (geothermal closed-Ioupi (,,i
2.Well Construction Permit#: L 1 FROM TO DIAMETER THICICN SS - MATERIAL
List all applicable well construction permits(i.e.U1C,County,State, Variance,etc.) lft. [_/ ft. 4./.1 r in. f.P z•21 P vG
3.Well Use(check well use): r ft. 77 9 ft -in. R
17:'SC E�El�. -
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural ❑Municipal/Public ft. it. in.
❑Geothermal(Heating/Cooling Supply) i('tesidential Water Supply(single) ft ft in
❑Industrial/Commercial ❑Residential Water Supply(shared)• 18.GROUT
:Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: to ft' r• ft. sem_Ci 4pb pod(ei _
:Monitoring ❑Recovery C. ft. „• ft. ,5Pv u M eJ
Injection Well: J ft. ft. /
❑Aquifer Recharge ❑Groundwater Remediation
119.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test OStormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
DGeothermal(Closed Loop) ❑Tracer 20.DRILLINGLOG(attach additional sheets if necessary)
DGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Rrmarks) FROM TO • ft. c--LIe DESCRIPTION(color,hardness,soil rock type,grain size,etc.)
Date Well Started "7-r-OvA34 CJ c;ft. y
4.Date Well(s)Completed: 7-1'-.)-oae pvell ID# 7 e3 .?p ft 1100.ft ri i ee(fd T,P/�``_ 4-{a ,,
5a.Well Location: r Phone#: ' 97,E ft. ft. !-s7
Facility/Owner Name f Facility ID#(if applicable)
l g 3 R,' 4 -ie '-' Q41q f Crj ft. ft. JUL 2 2 2024
Physical Address,City,and 7dp ( -3 ft. ft
• V It4a. , C.1 .tt,.; 6.'4:.!Bait
4
County J Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
-?rt' '3 .4 , l2! , ) / 7, aL 4✓ N 1 / w e 7'0• if��/6.Is(are)the well(s): permanent or ❑Temporary Sign a of e 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: ❑Yes or 2No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information add 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 construction info
construction,only 1 GW-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
/7 9.Total well depth below land surface: ' °0. (ft.)
For multiple wells list all depths if different(example-3Q200'and 2Qa 100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 6, 0 , (ft.) 24a. For All Wells: Original form. to Division of Water Resources (DWR),
If water level is above casing,use"+ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617IA
11.Borehole diameter: 6. (in.)Bjt Off: 6. b yG 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 1.9
`� )`A-1'`�' 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the it
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed lII�
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) S Method of test: a. it Permit Program,1611 MSC,Raleigh,NC 27699-1611PV
i 70% hth Date Site Visited: /d ai
13b.Disinfection type: Amount: /S,0 OZ Site Visited By:
t.
Farm GW-1 . North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018 t
Price:_