GW1--05467_Well Construction - GW1_20240912

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: i j
1.Well Contractor Information:
�- / 1 ' .
�8 dJ��d��l .ii WAT ZONES';-< a:s,:�;:ef.1"^1.'•."-4:`v,::.Fst3.': T�z i .r - -, •
Well Contractor Name FROM :TO - .,h.DESCRIPTION _
So J ‘ g$ ft. i yo ft,.2J
-20d°it a®9 ft.-- 41t
NC Well Contractor Certification Numb er °15:OUT121:CASING'(for•'miiltl cased:weI15ZORLINER(ifaPPbbb1e)1.1 '?1;
• Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL 6
Company Name � r� . ! nil. __
) , ,i16ddINNER CASING OR TDBING:'(ge'otSerinildoled=loopN±F"-( ;, ;a.L:
2.Well Construction Permit#: ��' 7 `� FROM TO DIAMETER • THICKNESS MATERIAL
List all applicable well consinutian permits(Le.UIC,County,State,Variance,etc) + I ft. .3 3 ft. • Ott I in. • 4_ ev-c
3.Well Use(check well use): •
ft ft 6, in.
Water Supply Well: e.7,:5(. -.' ..;- :L`E7..._: .Cf.*s,".y_ ,. Z7:7-7._ •�r V_'I
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
*Agricultural ❑Municipai/Public ft. ft in.
/ "-
❑Geothermal(Heating/Cooling Supply)" -• residential Water Supply(single) ft ft. in.
❑TndustriaUCommercial ❑Residential Water Supply(shared) `47:1_ _T_ _
�:Ig::S<O U'A,1"+':..... ,r......:'i:A,"I'•.",1� ':a.�''-.A=rwr�i�S: 't'�' J,7'4" IYr.
❑Irrigation - - ❑Wells>100,000 GPD FROM _TO MATERIAL EMPLACEMENTMETH-OD&AMOUNT
Non-Water Supply Well: 0 ft. ers— ft 31,,,1644.e., io, C..;e,„wi ®9
❑Monitoring DRecovery ft. ft
Injection Well: /1 p -
ft ft £/ CLT' 4.
❑Aquifer Recharge ❑Groundwater Remediation -_
if19 SCAND/GRAVIDPACK(ifa`p'plicable): t. :tsF =; ., t-1c
pAquifer Storage and Recovery- • ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD (11
❑Aquifer Test .- ❑StormwaterDrainage ft. / ft. i( •
❑Experimental TPrhnology OSubsidence Control it j, , ®°
❑Geothermal(Closed Loop) , ❑Tracer t20PDR1213NGVOG`aift'CIT aditlona•Iahee`tiif.necpeary)=` "�i 3
FROM TO DESCRIPTION(color,hardness,salllroek type,grain size,etc.)
DGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
Date Well Started 0 ft. ®.may it. J o
41
- 4.Date Well(s)Completed:' •- d-", - Nell ID#44� ft a ft. �, 6 9,�h
Phone#: ® ry y
5a.Well Location: • � 7� AO ft 22,� f' v Ai 6 544,
,' ft. ft.
Facility/OwnerName __��// Facility lD#(if applicable)a, ft ft. ! -� a , r
7 �•Y roses, A 1' � Elkpark ft ft i ti. `,P L..: ��A y tL r
Pb sicalAddress'-City,-andZip:- AtUeg ft ft.
t
/County, •- ' ." Parcel Identification No.(PIN) lr,/7.4.:V1'.- ?•rrcrr,r.7ur,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latfl�g is sufficient) 22.Certification: •
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36° P ifAill,N, lir) ,s-ge S 3.1, W „,„29
Signature of Certified Well Contractor Date
• 6.Is(are)the well(s): ►ai'ermanent or OTemporary
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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 To 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 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
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(add'See Over'in Remarks Box).You may also attach additional pages if necessary.-
construction,only 1 OW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: ry 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: • A.. (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q200'and 2®100) Y P
24a. For All Wells: Original forth'to Division of Water Resources (DWR),
10.Static water level casing;
use"+" casing: �� (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 '
If water level is above casing"use"+"
® !1 24b.For Injection Wells:Copy to DWR,Underground Injection Control(ITC)
11.Borehole diameter: ' C (in.)Bit Off: ,✓rk1Pa Program,1636 MSC,Raleigh,
,NC 27699-1636
12.Well construction method: e&,1 r -tt 4Ap 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the r
(i.e.auger,rotary,cable,direct push,etc.) - county environmental health department of the county where installed 2
FOR WATER SUPPLY WELLS ONLY: f
24d.For Water Wells producing over':100,000 GPD: Copy to DWR,CCPCUA
t ° Permit Program,1611 MSC,Raleigh,�NC 27699-1611
13a.Yield(gpm) <} 0 Method of test: cA coo f k
o Date Site Visited: A) �' c
4.
13b.Disinfection type: 70'a hth Amount: 4 pZ Site Visited By: . 'il 6 __ �°
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
Price: