GW1--04384_Well Construction - GW1_20240723

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: 03
1.Well Contra tor Information: I
?� t Y�.J 1 I if Pik Zt t^1 �r i 4.WATER ZONES
FROM TO D CRIPTION D
Well Contra for NSme �..
u G -� 0f aft ft pry....3.
NC Well Contractor Certification Number •�b V
15.OUTER CASING(for mai )OR LINER(itap licabTe)
Yadkin Well Company, Inc. FROM TO D THICKNESS MATERIAL (C.
L / ft. 66 ft. 6.12c in- qp,- at P 1/� l_.
Company Name 'i
'16:INNER CASING:Obt:TUBING,(q'e'titbermal doted-loop) e"'"%.
2.Well Construction Permit#: jkg FROM TO DIAMETER THICICNZSS MATERIAL.
List all applicable well construction perm&(i.e.UI ,County,State,Variance,etc.) R ftro
3.Well Use(check well use): ft. ft. in.
W Supply Well: s0-7-SCRW- .
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ❑Municipal/Public ft ft in. f�
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft in.
l`�'
❑Industrial/Commercial ❑Residential Water Supply(shared) :18 GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEM T lyiETHOD&AMOUNT
Non-Water Supply Well: ft. 2 O ft geoa t p G v G „pi
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft. _ .. ,
❑Aquifer Recharge ❑Groundwater Remediation
7 IS).SAND/GRAVEL PACK(ifayplieable)' I >) \_♦ 'I i!/t i !
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACI 1H''e9s- • •
❑Aquifer Test ❑Stomrwater Drainage ft• ft _ !I1 J 2 2024
❑Fltperimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer 20.MILTING LOG(attach additional sheets itnecemiryi i• Via'".� .)pt'
❑Geothermal(Heating/C hr Retiu,, er(explain under#21 Remarks) 0 t'1° 1 n> eRrPTION(color,hardness,ppt otk tspg grain arze eta)
Date Well Started_ 0 6 U J 7 )e",�.
4.Date Well(s)Completed:0(. U L il Well 1D#A —l Y9 V ft 6 6 ft A( n IIA,�
Ss We1lLocation: Phone#: g36- Y-69- 0770 6 h ft. 44 tit ad t`� l o-p ��P',t
Oat i A 3:-vw 4 Lf l ft' /5 ' a lF k y t.c.,,:14.-
Fac 1 nili Owner Name Facility ID#(if applicable) ft' ft'
oon
Physical Address, A City,and Zip l sIJ`I bl i ft. ft
dKi^ 21:REMARKS • g)
County Parcel Identification No.(PIN) al
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22. . 'cation
3`. 2J gal N Sso# 7 2 800- w51/ a '� vZ
6.Is(are)the well(s): (permanent or ❑Temporary Si: of C '.Well Contractor Date
` By ivth onn,Thereby certify that the well(s)was ere)constructed in accordance with 3
7.Is this a repair to an existing well: ❑Yes or dix. 1SA NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a copy (y
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. r..4
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
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. .M-
drilled' 7A.SUBMITTAL INSTRUCTIONS f0
9.Total well depth depth below land surface: / S 0 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths tfdifferent(sample-3Q200'and 2(41100)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (R•) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing use"+" �)
11.Borehole diameter: 6 (in.)Bit Off: b -V ( 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
1 Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: a S r (V r'\1r/ 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 SUPP Y WELLS ONLY: , 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA .4
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) s � Method of test: Q�''1 a 2� 1 —,s,`
70% hth Date Site Visited: (.,(k.a / KT.
13b.Disinfection type: Amount: 3 0 OZ Site Visited By:
Dc
Form GW-1 )epartment of Environmental Quality-Division of Water Resources Revised 6-6-2018