GW1--06179_Well Construction - GW1_20230922

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`� �CONSTRUCTION RECORD (GW-1' For Internal Use Only:
1.Well Contractor Information:
Cr�a to .e_ J irca,1O'C 4:WATE$.'ZONES`;'r:-_'::�_
�/Y l•, S ( Bt FROM TO DESCRIPTION y (,�
Well Contractor Name �q
• zo ft. 0-7 ft / .0 yv
��{� r A
sell ft. G r ft 1�J Q�
NC Well Contractor Certification Number ';15iODTA:It'CASING(for'iiiilti-casedwelfs)'.ORLINER'(if.'ip'licable), _...--' _• _ `9
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL
4, ft. 6 3 ft 4,lgs in. i f D K r 6 f� -..„,„ 1.
Company Name l
'.16.INNER'CASING:OR.TDBING:(j;eotlierinaldo'sed=loop)' _ . . __ _ ..
2.Well Construction Permit#:NA.D 2 2.- ® /..3 ( FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well cansintetion permits(Le.UIC,Comity State,Variance,etc.) ft ft. 0
3.Well Use(check well use): ft. ft in.
IiIWater Supply Well: 7'SCREED.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL ('ice
❑Agricultural ❑Municipal/Public ft. ft in
❑Geothermal(Heating/Cooling Supply) Effeesidential Water Supply(single) ft ft in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) :ILGRODT.`. v
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: • 0 ftO d`- f t Be pii:le aj,pj P d-4rie- t.-• Pk-4 ic--
❑Monitoring DRecovery ft. ft. /-/ a(5 4 6 ��`)-� 3
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation CA
i•:19.SAND/GRAVEti PACK(if a`p'plicalsle) •
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD A'"
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft ,
❑Geothermal(Closed Loop) OTracer 20.DRICIiNGLOG(attach additional sheets if necessary) _FROM TO DESCRIPTION(color,hardness,sail/rock type,gram size,etc.) i❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
Date Well Startedb7fSep4/9'3 C) ft. (L) ft ,e►t r evoc.v:�-
4.Date Well(s)Completed: / jArki Well ID# AA p' ( i j(i ft. 6,01 ft. Da c lc q5`t✓S` eper!1t)/
Sa.Well Location: Phone e -•t-/ eG q j (o ft. ?Cf 2 'ft flravc/S , Lsi�.c.s/ -"7/ tlik Le
...t . 1 .vc baq-s a:t/1' ft. ft
Ye, ,44.-S lcc 1 Li t&e. 3J(.- c'a--3 r2_t:
Facilitty/!Owner Name / Facility ID#(if applicable) ft. ft. r- `�_T y •�
31l Ti-zt�t r j �Y l 14•f'A e-1 a...-.��t ft. ft 1...:.1,L-Li,L.,i V:' 'L.)
Physical Address,City,and Zip d 1,a 2 . ft. ft op)D ) 9 7 Q 7 `
ii21:REMARKS;_ 01 d' .d f!-• w -
/� 8
County VO / Parcel Identification No.(FIN) i'f:-;:;3--;^i1 ;ar--.7zes ri:,? UnI
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees
(dwell field,one lat/long is sufficient) 22.Certificati n:
�- r° N '7 9_ 2,s' 3 a a 5; �o2 ��
// oI �' �a
6.Is(are)the well(s): l Permanent or ❑Temporary Si ertrfied?Well Contractor Date
ing 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 l9tslo A 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 t e 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
conshuction,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: 3 I/a (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3(g200'and 2@100`)
10.Static water level below top of casing: 50 (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+" / Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) Off: 6.//3 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
L Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 4 t✓' A O 1-`---,/ 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 l jt
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
�( ° Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) U Method of Pest: d� 2 •
70% hth [- OZ Date Site Visited: i
13b.Disinfection type: Amount: Site Visited By: l
Z --5
Form G . j nent of Environmental Quality-Division of Water Resources Revised 6-6-2018
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