GW1--04386_Well Construction - GW1_20240723

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: '
1IK CA
3 0 t l U \( '•.:14.WATER ZONES t .
FROM TO DESCRIPTION
Well Contractor Nam f
/ 7 h• /70 1't Clh VjQ T A. 2a -e- c' i,-,,
�-5 7( 1)-Sd r fL Asy-'ft Jo - 0- et-t :"L�
NC Well Contractor Certification cation Number 15.'OUTER CASING(for multi-cased wells)OR LINER(if'sipplicible) 0
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS _ MATERIAL - S
ft. ft. in.
Company Name
2.Well Construction Permit#: I
J 0 tia IA/
.16.INNER CASING OR i USING,(geotberinal closed-loop)
FROM TO DIAMETER _ THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ' ft /0 yft. G e/?.5/in. Jo i F1-D( e
3.Well Use(check well use): ft. it in.
Water Supply Well: ,7.SCREED.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) %esidential Water Supply(single)
ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) : 18:GRbU.I,
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 6 ft. S- ' ft t3-m-c.k. s p s v re,"
❑Monitoring ❑Recovery S. ft. .70' ft r3eft-5t.r7s/ P✓rqr��/
Injection Well: ft. fr. /
❑Aquifer Recharge ❑Groundwater Remediation
i 19.SAND/GRAVEL PACK"(ifapplicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL _ EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soilirack type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
Date Wet Started 7 9- 20 0. 0 ft. ?I ft. -5f;,' /�1t d1
4.Date Well(s)Completed: -I¢-�u -y Well ID#AAA '� � �� ?a ft 0 7C.it iv;..,-,1 `Jo - 1 ,..u . !t r�1 1 apt. -4
5a.Well Location`' Phone#:3G1 f'' ifs`' fan <}7t ft. C�.�3 it hind ger'//o !'Jinn/ 1,�1 GA/'i!/.Ni-
-Jell i1 kilt se R t ft. ft. - kilt.It a 7 C ( f still.
Facility/Owner Name Facility ID#(if applicable) ft. ft. , _,
ft ft i ••:-- ' j
Physical Address,City,and Zip ft. ft. I ') )r 7 4
VV :9 L`e; 21:REMARKS
County Parcel Identification No.(PIN) ,td'v:i:,h..• ' .. '.+Fw.".ti '..4.,i C`
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
366 f 1 f 44 4 N iS I 07 y f S-2 .. W 7, /< i';jr., ' 7-/!- 0 1 Y
6.Is(are)the well(s): {Vermanent or ❑Temporary Si ure of T�,,ed 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: DYes or klo ISA 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 remark 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: ( 3 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 4/J 3� (ft.)
For multiple wells list all depths if different(example-3Q200'and 2Q100� Submit this GW-1 within 30 days of well completion per the following:
24a. For An Wells: Original fonn 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 (in.)Bit Off: 6,)00 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: A i f rz-6/,Z 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the I
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
6-
FOR WATER SUPPLY WELTS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA Permit Program,1611 MSC,Raleigh,NC 27699-1611
l Av
r1
13a.Yield(gpm) IMethod of test: f% cti r 'S-
70% hth r Date Site Visited: f- 2 3 ,?if13b.Disinfection type: Amount: /c! , ' OZ Site Visited By: 6Cg)
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
Price: