GW1--07500_Well Construction - GW1_20231120

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor ormation: I '-
y 4
. `+a�vf l I tr 1'� iTi4 WATERZONEs _,3"_.;i-aW.'�.Y'?:: :- U.-_:��" ,vim._:_._;r�,..-....,t .
Well Contractor Name FROM TO ti DESCRIPTIONCr-
" 610.-A i ft. ./ ft f 1 . / I-
--,NC Well Contractor Certification Number e15:OITTEITCASING'(foe'mnlfi=cased:?iieils)'OR72NEM(ifip licabie)=_
Yadkin Well Company, Inc. FROM/ TO / D THI15 1 MAT>TT
FROM/
ft / in.
Company Name
i.% -1.01NNEfeCASING:ORTEIBING'7(t e'o-tliermirelosed:kao it ' 17 %:;;
Z.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) Jr 1 " Q �1i " 6:I ; in. 1,-.1,- 2 l i/1"'v�
3.Well Use(check well use): It. w/K•/ ft ( in. / { /
Water Supply Well: • 17i: CBFiE1`)t
FRO7 T DIAMETER _SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public ft ft / in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft /
in. / /
❑lndustrial/Commercial ❑Residential Water Supply(shared) ,- ///_---_---_---/-- -__-
•
Oh-ligation ❑Wells>100,000 GPD FROM TO g MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' .�9 ft 1 j c 19. . N Grit., t / 1 a',o 17..,,I
OMonitoring ❑Recovery ft
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
i_I9:./ft.
D/GRA "PACEC.:(ifapplicable:__--_---.—.._.--..__- �.`-_s::
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIALS EMPLACEp"IENTMETHOD
❑Aquifer Test ❑Stormwater Drainage rt. t. //❑Experimental Technology ❑Subsidence Control t. ft /
0 Geothermal(Closed Loop) ❑Tracer i-20 DRTTIANG'Y;oG'(ittach idditiefnaj:sleefi'ifneces ary)`._ __ '-T _:__,
❑Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,sell/reek type,grain size,—eta)
Date Well Started 90 3-a3 +ft. ft' tw aI
4.Date Well(s)Completed: 0• —2 ' Well ID#'
4 OO ft.� c� f/0 ft P4&,ftdt s,,;t __
5a.WellLocation: Phone#:g' t°� '�
" � y q�tr1 ft. 16 tI ft 1 01a-livii -- Vot_t: L1`,'vi
11
Rob et+ GretA p( ft 4.c) ft. ci.t-.,
,r.'� ,, a ,y ,
Facility/Owner Name
Facility ID#(if applicable) ft ft.
.
--
Vitp r�at�eL 'An Y LkeeQs P 9ve Z®tir ft f
Physical Address,City,and Zip • ft. ft ., .. `;7p 'i
• County Parcel Identification No.(PIN) ,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one let/long is sufficient) Li Or-1 22.Certification: ''• '
-,.- . 3C° Li ® SS" N /c 1 6 3S s LH" W ,.-2
6.Is(are)the welI(s): 'ermanent or ❑Temporary Signature of Certified Well Contractor Date. r
By signing 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 ' No ' ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
elms!,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: (}1
S.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 at
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. ---I
drilled: 1 24.SUBMITTAL1NSTRUCTIONS f�
9.Total well depth below land surface: �t o (ft) Submit this GW-1 within 30 days of well completion per the following: Q.
For multiple wells list all depths ifdifferent(example-3@200'and 2®100`)
10.Static water level below top of casing: 1 ) (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR), a-
If water level is above casing,use"+"
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
-11.Borehole diameter: C (in.)Bit Off: 6, /tic. 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IITC)
l,✓ Program,1636 MSC,Raleigh,NC 27699-1636 2z)
12.Well construction method: a,/ l,5`-el s a, 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the CFI(ie.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY, LLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA CA
13a.Yield(gpm) Method of test: ri ce ,/ Permit Program,1611 MSC,Raleigh,NC 27699-1611
70% hth q ,Date Site Visited: elm V 2 3
13b.Disinfection type: Amount: 1 Oz Site Visited By: A/5 , Qg
Form ow-I • - ___ _ _ __ . North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018 •
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