GW1--04391_Well Construction - GW1_20240723

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: =
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1.Well Contractor Informaion:�
3aCl W42.4 4tAS ,Ti. WATExYZONES _'.. 1+
FROM TO . ' DESCRIPTION p
Well ConnactorName • ft 2 ft cP� d�f� ^.s[s/1(m
' L{S., A ft. lbs ft I G Pm 7�7
NC Well Contractor Certification Number ;13"OIITEIV(isASAHG'(fo[mnlli-Wised:welliTOIi7'.7NF'R(ifsp lfairel::. .
.DIAMETER
Yadkin Well Company, Inc. FROM TO .DIAMETER THICIINFSs MATEIIAI.
ft. ft in.
Company Name
3 'VI
� ��� 316`7lVNER;CASINGORTI7BIIiTG:(g�otSermiil'c]a""eed=loop)"
2.Well Construction Permit#: FROM TO • DIAMETER THICOSFSS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance.etc) , 1 J ft '�a,3 ft G s/8 m- . 1207 v 0
3.Well Use(check well use): ft ft in. �t+t
Water Supply Well: FROM 1
FROM TO DIAMETER SLOT SIZE THICKNESSC®
MATERIAL
❑Ag iculturai ❑MunicipallPublic ft. ft in
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft ft. in. A
❑Industrial/Commercial ❑Residential Water Supply(shared) :18'GROUT::.
❑Irrigation ❑Wells>100,000 GPD FROM TO LMAATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 2 rt. 1401. Phis
❑Monitoring ❑Recovery 3 ft ,Q ft an GrodiV P R basEr
Injection Well: ft (( ft
❑Aquifer Recharge ❑Groundwater Remediation (14
❑A infer Storage and Recovery ❑Salim Barrier )'I9.SAND./GlYTrV.E1?l:AtlietitWifIAil l _ "
4 g tY FROM TO MATERIAL EMPLACEMt1.11 dTHOD
DAquifer Test ❑Stolmwater Drainage ft. ft
❑Experimental Technology ❑Subsidrncr Control ft ft. l -
❑Geothermai(Closed Loop) ❑Tracer :20.DRIt,LIIVG LOG(attich iaditional sheets if riecrssaiy)' :i„
❑Geethetmal(I3eating/Cooling Return CI Other(explain under#21 Remarks) FROM TO DESCRIPTION(calor,hardness,sail/rock type,grabs size,etc.)
Date Well Started [� Z6 �(J /) n 11-- a b0 ft St 1
4.Date Well(s)Completed: `7 f)i T Well ID# 44 a - 2 33 ,D 00 ft- fop ft G ram,
5a.Well Location: Phone#: 2. er' 3p0 ft (SCOW/6 ROC,k
82g-A'i, -4H80 aft. ft
Mi C �a`A % 1LSS H;br14Ln 7�0 /oa ' G rani�c ....
I
Facility/OwmerName Facility ID#(ifapplicable) ft ft - ••'4 l -r``
Physical sork.CL,and0.,..4,y,,
° 11�11._(ToVCOi ft ft JUL 2 2024_
County Parcel Identification No.(PIN)
tr-
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one 1st/long is sufficient) 22.Certification:
36 , (1S Is Li N 1(1 t 59 VIc w lit lJY91
6.Is(are)the well(s): ermanent or ❑Temporary signs of C ed well Contr :tar Date
By signing this form,I hereby cc,,:fy that the well(s)was(were)constructed in accordance with
t
7.Is this a repair to an existing well: ❑Yes or l'INo ISA NCAC 02C.0100 or RSA 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 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: / 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1 00 3
(ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths tfdifferent(example-3Qa 200'and 2Q100)
0 24a. For 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 wain'level is above casing,use"+"
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.)Blt Off: Program,1636 MSC,Raleigh,NC 27699-1636
i
12.Well construction method: Ai e r r0 fa y 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,CCPCUA
13a.Yield(gpm) 4 Method of test:_C/y Oi(/ Permit Program 1611 MSC,Raleigh,NC 27699-1611 (A
70% hth !/!J/ Date Site Visited: /0-Z 3 �t
13b.Disinfection type: Amount: L1 ! OZ Site Visited By: M 6 t jam_
Gel 4r.t�F ', y- L Z-z 4 'r
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
Price: