GW1--03437_Well Construction - GW1_20230516

e-WeLL CONSTRUCTION RECORD (GW-1) For Internal Us
Only: v
1.Well Contractor Information:
�i72�� `.1 '2✓b�/+"� � • n14'rWATE1tZONFSC:: v;i:_ . _:..'
Well ClontractorNamer FROM TO DESCRIPTIONfL
�S ft. �Sl� ft `e liVl
NC Well Contractor Certification Number CI3:"Ol1TER:CASING fd"r miilfi=cesed:�vells:ORI;INEIt lia licii5le 1-: _"
Yadkin Well Company, Inc. FROM To DL9METER Tfficlau11ss MA QQ
Company Name t , % ft 6,19s us Sf��"p 1 ___.___ Ls
16fDUUM•;CASING:ORTQBIIYG: 'eot)itiinaldosed=Itio '" __.__.
CP
2.Well Construction Permit#: UJ L 20 2 2- (a 9 9 FROM TO DIAMETER THICI4•iLSS MATERIAL
List all applicable well w sstrvction permits(z.e.0C,County,State,Pariance,etc) ft m
3.Well Use(check well use): ft' -7. ft
Wa r Supply Well: r 57CA17 FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agdcultural ❑Municipal/Public ft / ft in r
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) t ft
❑lndustrial/Commercial ❑Residential Water Supply(shared) UTC _.— _-_-__ _
❑Iui lion ❑Wells>100,000 GPD FROM TO EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft 3 ft ! ae
❑Monitoring ❑Recovery ft t f
' �� n
Injection Well:
ft. ft
❑Aquifer Recharge []Groundwater Remediation
❑Aquifer Storage and Recovery ❑SalinityBarrier FROM
TO f�2AVEL•PACFI MATERIALe.:. -- EMPLLACEMENTMETHOD`..._
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer e20:1)RI]CSSPTGIOG`attacli'adiiitional"slie'etiif:necrss"
❑Geothermal(Heating/Cooling Return El Other(explain under#21 Remarks) FROM To DESCRIPTION color hardness,so!Vrack type,grain size,eta
Date Well Started y� s�p 0 ft. it S. i( �� � `--e. 5
4.DateWell(s)Completed; Well ID# Y ay� ft 3 it e ��
Phone#5 —4 ` s, ft. ft I.
5a.Well Location: B �1�` G
R�, � �®e�I �� ft. f t ('react s mL '
Facility/Owneer/r��N))ame yy�— Facility 1D#(if applicable) ft. ft
-0-4-4� 1 , !AE/
Physical Address,City,and Zip ft ft
1 C
County Parcel Identification No.(PIN)
' wda�d�+y'L1t.r1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(Ow'ell field,one IWIong is sufficient) 22.Certific ton:
a ��tl N . I� .r �� &Y10
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6.Is(are)the well(s): 2Krnanent or ❑Temporary S' of Certified Well Conhactor Date
y signing this form,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or Mo 15ANCAC 02C.0100 ot•15.4 NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and explain the nature ofthe ofthis record has beenprovided to the well owner. L
repair tinder#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 I GW is needed. Indicate TOTAL NUMBER of wells (add See Over in Remark Box).You may also attach additional pages if necessary. J
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft) Submit this GW-1 within 30 days of well completion per the following: ^�
For multiple wells list all depths ifd8erent(example-3@200'and 2@100)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: go (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use"+"
Q� 24b.For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
11.Borehole diameter: (in.)Bit Off: 41
^/ �� Program,1636 MSC,Raleigh,NC 27699-1636 �
12.Well construction method: t D 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(le.auger,rotary,cable,direct push,etc.) county environmental health department of the county" installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100 000 GPD:_Copy to DWR,CCPCUA
13a.Yield(gpm) QD Methad of test d �s+ Permit Program,1611 MSC,Raleigh,NC 27699-1611
70% hth Date Site Visited: �-i6—2 3
13b.Disinfection type: Amount: � OZ Site Visited By: p:Vj
Form OW-1 _ North Carolina Department of Envirortmental Quality-Division of Water Resources Revised 6-6-2018
Price:_