GW1--06034_Well Construction - GW1_20241011

WEi -^"` S u.RUCTIION T 'COED (GW-i) • For Internal Use Only:
• . �
I.Wel:Contractor Information: I
JCcrl W0,4 kt 45 14.WATER ZONES $
R
FROM TO DESCRIPTION
Well Contractor Name • ft. ft.
I �r
4 SiP A ft. ft. I ,;
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER THICKNESS MATERIAL 7 •:.I
YADKIN WELL COMPANY,INC.
Ct ft. in. �, �'�,.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop) 4
2.Well Construction Permit#: W I 0 i O®-I;TS- FROM TO DIAMETER TffiCI ESS MATERIAL
List all applicable well construction permits(1.e.UIC,County,State,Variance,etc.) ft. �1 t. in. /jU�
ft. ft. 1n. tr1
3.Well Use.(check well use): �(•L�
Wat.�r.Supply Well: FROM
SCREEN
17.TOAt TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ' ft. ft. in. r
•'• ❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in. C-g
❑Industrial/Commercial . . ❑Residential Water Supply(shared) IS.GROUT (4
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
NanlWater'Supply Well: a rt. 4 co ft. Tom.. I O� •_ & 4
❑Monitoring •• • ❑Recovery ft. ft. ^
Injection Well: ft, ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable) Li '•
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD D
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑ erimental Technology ❑Subsidence Control ft. ft.
3dGe6therinal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary) •
❑Geothermal(Heating/Cooling Return) El Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardnesr,soil/rock type,grain sue,etc.)
6 ft. ft. weet1-4•eed reicr
4.Date Well(s)Completed: q/iOI ay Well ID#A A P'°q 241110
80 ft. Y00 ft' Gt amn( .
8"28- 217-rr�1O9 ft. ft
5a.Well Location: ^ Phone # sQt,:c� S,ty,6aV ft. ft .. 9 n
.1 1QVc v 3 OaheV ti�,.0 ,, '
t,
' Fac%:ty/Owner Name Facility ID//(if applicable) ft ft.
yDtO eP'1 5L 1=-CL /10 t Q� av 1di° ft. ft. OCT 4. ..... LUL4F
w ft ft. ir::: _ .;b".;,.7):-...-''''--- -
Physical Address,City,and Zip W - "" ,� !i:A
�C.fIt 21.REMARKS � r G.+.t.ct C5
Courly. Parcel Identification No.(PIN)
BORES (17A) DEPTH .(9-3Q' --- - - - (50
• 5b.1atitude and longitude in•degrees/minutes/seconds or decimal degrees: LOOPS PER BORE ( � ) DIA OF LOOPS (�,
(if well fielci,nntlatnongissufficient) 22.Certification: SDR OF LOOPS ( Il )
eS- N �, 2- 3 7 d W L� ps i
.o..-7 -z 8�7 6 9 Ito'04
6.Is(are)the well(s): 141fermanent or ❑Temporary Signature f CeitiS d Well Contractor Date
` J By signing thisfotm,I hereby cert),that the well(s)was(were)constructed in accordance with
7.Is'this a repair to an existing well: ❑Yes or I�PCo 1SANCAC 02C.0100 or 15A 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 W-1 is�leedpd. Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 1 4.3 24.SUBMITTAL INSTRUCTIONS
):Total well depth below land surface:o LI 00 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if derent(example-3 a 200'and 2©100')
A1l 24a. For All Wells: Original 'form to Division of Water Resources (DWR),
10.Static water level below top of casing: JN/ (ft') Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water ledel•.ls_above casing,use"+"
11.Borehole diameter: CA' (in.) Bit Off: 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
• Program,1636 MSC,Raleigh,NC 27699-1636 c-Q
AIR ROTARY
12.Well construction Isthod: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to theme
(i.e,auger,rotary;.cable,direct push,etc.) `" county environmental health.department of the county where installed
FOR WATER SUPPLY WELLS ONLY:
to 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
♦ - Permit Program,1611 MSC,Raleigh,NC 27699-I611
13a.Yield(gpm) � Method of test: / I
13b.Disinfection type: 70%HTH ;;.I Amount: , OZ DATE SITE VISITED: f
ps;:cP_
i •r�P • VISITED BY:
Fenn GW-1 • .- 2' North Carolina Department of Environmental Quality-Division of WaterResnnr-es n..a...t a_r;_•im u