GW1--04385_Well Construction - GW1_20240723

�� WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well C n4 tractor Information: _iZi
I.BLS 11 4i WATER'ZONES' '=
Well Contractor Name FROM TO DESCRIPTION
4io -A
aoaft. 40 t sit, 'fa'f/✓'" / la 919kr%
to ft. ✓j ftZ 2�r 0
NC Well Contractor Certification Number
1�,'pIITE1;'CAgING'(foimulb=eased wrat)ORL7 (tfsltcae : • ��
Yadkin Well Company, Inc. FROM TO DIAMETER- THICKNESS MATERIAL)
ft. ft. in.
Company Name
0 \Vi alb IPINF-R:GASING'OR:ruktING_'Wcim ttii al doled=loop. :
f�
2.Well Construction Permit#: �J FROM TO DIAMET1 THICKNESS MATERIAL'/ (P
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) „ , I ft 11� ft C.12 (' in. ,S )e 2 1 7I
3.Well Use(check well use): ft. ft in.
CY
:'_17 SCREED:
Water Supply Well: FROM z TO DIAMETER,SLOT SIZE THICKN MAT
❑Agricultural ❑Municipal/Public ft in
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) _
ft ft, in.
❑Industrial/Commercial ❑Residential Water Supply(shared) r , . ...
=18:•GRODT:, •
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL I.ACEMENT METHOD Id A�M�OUN�T+ 03
Non-Water Supply Well: (� ft. 2.1/ ft. )3 C`.1'rx b/ V l / i 1 'J"'�.1
❑Monitoring ❑Recovery vv ft. ft. I (1s
Injection Well: - •
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
❑A uifer and Recovery ❑Salim Barrier i'19.SAND7GRAVF. P.ACFe(i 'app7icabte)'$" :
Q Storage tY FROM7_ TO/ MATERIAL EMPLACEMEN METHOD /\
❑Aquifer Test ❑Stoimwater Drainage ft. ft ✓���
❑Experimental Technology ❑Subsidence Control �ft. ft
(
❑Geothermal Closed Loo ❑Tracer '20.DRILtINGLOG(attach Qddifioiialiheetsif:uec'ess :.rl
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DES CAPTION(color,hardness,soillrock type grain size eta)
Date Well Started 6,-(9--2 / "� Q t) ft qS ft _ _,'_(
4.Date Well(s Completed:6- s- 21 well Lo#A/�a -d c$ ft. I /Q ft c(' ��G 6Wa -
5a.'MAa on°Plair4itS Phone#: 316- Yl-2- Cj i Z fft O ft '+64t�
J ets0A ` Sh i 1ah no�Lr ry i '� 0 ft. -30 ft ivy1t''L Oa- kard-
N
Facility/Owner Name FWlity 133#(if applicable) ft. ft'
ft. ft
3Gna PA_ 1 le Alors 'KiE ft. ft - 1 �.''
Physical Address,City,and Zip (f�q
W I, 11kz5 IA 2�. ARI JU V, `-?824 a
County Parcel Identification No.(PIN)
(fr(G:;;k.L1^1l ,''•"^$irv,;-,t l..)?:ii
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: DI:"C,'1':G 0)
(if well field,one 1sUalong is sufficient) (° 7 22.Certification:
3 . -(f vl;7 N (f/, is/J-i W = /_r7'2 . g
6.Is(are)the well(s): Permanent or ❑Temporary Signature of Certified We Contrac r Date J
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 "(No ISA NCAC 02C.0100 or 15A NCAC 0:?C.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 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: l 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 34.2I
' (ft.)
For multiple wells list all depths if different(example-3Q200'and 22Q100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: / S (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: C (in.)Bit Off: 1 1
1?1- 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: ra-! r /)J ff-Ln 7 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copyto the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed a
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611 ('�_
13a.Yield(gpm) 36 Method of test: &(!
70% hth Date Site Visited:
13b.Disinfection type: Amount: OZ Site Visited By:
- ' - ment of Enviromueutal Quality-Division of Water Resources Revised 6-6-2018 9
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