GW1--06191_Well Construction - GW1_20230922

i' E�,T,CONSTRUCTION RECORD (GW-11 For Internal Use Only: •
1.W Contractor Information:^ i
i! bu-ce -eeD It//�J K'.14iWATERZONES<z:c. C.-=r;�';` - .-_ ...:- _- f
+ �"-' FROM TO -.DESCIU TioN
WellC3trac 3 g -eq- . ��y�\ fL 2.1 c ft is ft. sob ft a1���.//'�f v- ,
NC Well Contactor Certification Number i 11
:15:ODTF:S CASING(foi multi-ccasedlwels)'OR LINER'(if ap'Table)i `_ .::.:.,
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL
TL i ft' pi ft {16- in. SIJF-d i .Pius c,
Company Name S��y 3 SC.- o(- fl )' '16 IMERC ASING:OR:TUBING wittiermalclosed:too _ ,
2.Well Construction Permit It: V1: � 01. w 2.3 CI 2. O
FROM TO DIAMETER THICKNESS)Y MATERIAL
List all applicable well construction permits(i.e.UIC,'County,State,Variance,etc.) ft. ft in.
3.Well Use(check well use): ft. ft in.
er Supply Well: r,],TSCREEN..% ...:, w.�s:� _.::r =: ;.t'- <:: ._ _.-.�'; :" _ _3
W
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Q'Agricultural ❑Municipal/Public ft ft in. CA,
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft. in.
❑IndustriallCommercial ❑Residential Water Supply(shared)•
❑Irrigation ❑Wells>100,000 GPD FROM TO FIATERIAL EmpLA Si to
METHOD
MET HO D&AMOUNT `
_
Non-Water Supply Well: C, f. ')Q ft' e'1"';.1e(4,;15 yc i4_ f'_s e .C..Zs_A
❑Monitoring ❑Recovery ft. ft IsI' 1. �& 0.Injection Well: g
0
ft. ft
❑Aquifer Recharge ❑Groundwater Remediation 'T
h:191 SAND/GRAVEL PACK(if spplic ble) ":: :I:,.'."1:"`_';.._:.;:_ .-__:="i.,_::1.
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology 0 Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer `20iDRl)YLING LOG attach`additional-sbeeti if access ;` --- '"
❑Geothermal(Heating/Coolie Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,sail/rack ty/pe,grain size etc)
Date Well Started "7/. us�/� 0 ft qrokA ft'
fro+` ( 'F 4e_ OS t 7/bi��
4.Date Well(s)Completed: _s P Yell ID# ,&4 7 C / to. ft. -›c_, ft LA e ys :e��'S®;
Phone#:.1%-3 �'O&S ft. ft. 4 y c cif`+ // c ,
]� 5a.Well Location: ( �® �� �G'°"` �� �`K' `�Ifi"/-
tt►rij l i'd' Td5 Ls Lute _arm ��ft. t 2. ft L G-yetr 5I G(K-Y/ r► O G*-v�-'�i t�
Facility/Owner Name
/� Facility ID#(if applicable) ft. ft f ��4-
C(k C (re(' �c f- /06e:ck, ft. 7.i� F.. ,-4 f 'F." -}I
��� ft.ft. ft. t"c.+.-(v'1....i to 4- ..I
Physical Address,City,and Zip
. f`y .....'
• :-
i BEWAILS�,''. :i .7,::t!. "., : .o f?•ti�.f __
rtdI. IT S� L..,
County Parcel Identif cation No.(PIN)
f
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: G ;w' 0,;:.;
(if well field,one lat/long is sufficient) 22.Certification:
36 N Oc'.rcIt/ W („„,/,) 2 �
6.Is(are)the well(s): Permanent or ❑Temporary Signa,, si edWell Contractor Da e
L� 'rig this form,I hereby cerhfy that the well(s)was(were)constructed in accordance with ,,�i
7.Is this a repair to an existing well: ❑Yes or l9�Yo - 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy W
If this is a repair,fill out known well canstructioconstructioninformation and explain the nature of the of this record has been provided to the well owner. Ara. I
repair under#21 remark section or on the back of thisfotm. 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: % a (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if d Brent(example-30200'and 2Q100)
10.Static water level below top of casing: IW0 (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: 6 (in.)Bit Off:gs MI 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 4.‘.. R O J`n'r 7 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
1) Permit Program,1611 MSC,Raleigh;NC 27699-1611
13a.Yield(gpm) 3 / Method of test:14.'(� �'S '
70% hth �j OZ Date Site Visited: � --' pee"., ^�
13b.Disinfection type: Amount: Q Site Visited By: ®:9 • ka1 t vti yY.7LF, 16 ly,a"
Form GW-1 ,_____ North Carolina Department of Environmental Quality-Division of Water Resources i 4t e,,,2 9 I. Revised 6-6-2018
Price:_ --,