GW1--06203_Well Construction - GW1_20230925

i
LL CONSTRUCTION RECORD (GW1) For Internal Use Only:
1.Well Contractor Info a n: �mVd�a pine
iia /'04/ 43,WATER`ZONFoSM, !iistZfAt r,',--i=;`-1::zIt.f. -:::_.'.F,t,.&I .�..n'Li-,-_:.. ,
Well Contractor Name FROM /TKO DESCRIPTION �
.3o se A ash ft 9s it /o Cog .1 uP6
ft ft l Z
NC Well Contractor Certification Number
5:311 EIt:CA.SING:(fri=%mriIti ce"sed>wells':ORL NER-,(i W1 calile):.'':;'Y.;`.<:,'7gr
.Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS 1 MATERIAL p�
ft. ft. V
' :in.
Company Name Dai.4 t 3' C_ r3'®� t.a ^`lV
® ;:16�INNER�CASII1iG:OR'TIIBING(Re"otlierma7':d'osed=to"op)r"�.xi"' •:_...'�'.z.t'.i�
2.Well Construction Permit#: T� fi�7 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Comity,State,Variance,etc) + I ft 3 9 ft G 385 83 In- S IDQ_0 I tl u C.
3.Well Use(check well use): ft ft In
Water Supply Well: EX.V a1 ; :_..,: --„�--._.• • --------- --- n
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipa]/Public ft. ft. in,
❑Geothermal(Heating/Cooling Supply) )ilg.esidential Water Supply(single) ft ft in.
❑Industriai/Commetcial ❑Residential Water Supply(shared) .`I8 G1tOUTC" 7--' --- '-- V_ ,
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL •EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0 ft. ft. i fe ik i 4. e n a-e-c__
OMonitoring ❑Recovery ft. ft �
Injection
Well: ft. ft 3 �
❑Aquifer Recharge ❑Groundwater Remediation
DAquifer Storage and Recovery ❑Salmi Barrier (19'SAND/GRAVEL'PAGKCrf applica' Ie):V_==42:- �-'"�.,; w, :7.
g tY FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test ❑Stormwater Drainage ft• ft. ,
❑Bxpetimental Technology 0 Subsidence Control ft. ft -
❑Geothennal(Closed Loop) OTracer [=10:DRTTSIIGI;OG"(dttirai`-additional'sheeta if:nec-es'ary)`__ -"
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FRO
TO DESCRIPTION(color,hardness,sell/rcek type groin size eea)�
Date Well Started/ 0141•. 9 (.) ft t i ft . S'�;194oeS a ,. -ear.." ,•,,
4.Date Wells)Completed: l3 /`�3 wellID#I9�P a.C744," ,c� ft `�/ ft fine'k, �; ' t4-0 "
5a.Well Location: Phone#: [phone]'�,3() 31 ft. /a a ft ( /r. ee.e., 4)4.',t �,.,r e,,5
t 331.- LI N-3i, 7 / /� y
Ala �A&n L��Is4t, Sewcw.s Ina ft.
9 �acAr e..,.,,./f=Q4t'/t L"
Facility/Owner Name o /)_ Facility ID#(if ap licable)
Wl'nANr�S1l gg 5 till , ft ft �at_t i r(!.«n
Physical Address,City,and Zip p AaW c*e,pc ft ft I I%'W.-`+'s...t or +.� C
g.
County Parcel Identification No.(PIN) teit
lnlorlr cn Pr::,,:v ;e.-1 l,nc3•
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ''
(if well field,one lat/long is sufficient) r -
q pp�� 22.Cer. cation:
3Sa' �"q I 0?�.�i N 80® 30lS/i W
6e, . i 1
6.Is(are)the well(s): rmanent or OTemporary Sr•• of Certified Well Contractor Date
going this form,I hereby cerufy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or AIo A NCAC 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 aphis record has been provided to the well owner. ,a,
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details: ��i
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 r '
construction,only 1 G�V-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box)-You may also attach additional pages ifnecessary.
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ,g 0 (ft) •
For multiple wells list all depths if different(example-3@200'and 2 a@100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: /0 (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. .E.'i 7 5 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:b, tt v �� 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copyto•the
(i.e.,auger,rotary,cable directct 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
13a.Yield(gpm) a' Method of test: / Ad/' Permit Program,1611 MSC,Raleigh,NC 27699-1611
70% hth Date Site Visited: .S I`7- .1 2
13b.Disinfection type: Amount: OZ Site Visited By: Ai b 6, . rat / 4
• iNI
�� 4 ,,,.3 . �t�. l8.
Form GW-I No_rth Carolina Department of Environmental Quality-Division of Water Resources Ia V. Revised 6-6-2018 L
Price:_