GW1--07532_Well Construction - GW1_20231120

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WELL.CONSTRUCTION RECORD (GW-1) For Internal Use Only:
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1.Well
Contractor Information: c
Gdt-ti V)1,13 t � 0:4 wATER•zoNEs 1, ...:::.;.:,;-:::,:war„;;
'a. `'::c,..-'.� 'i. ��:: '.a__., ... ,_ - . :7:.�. ::
Well Contractor Mine FROM TO DESCRIPTION
/AD ft. /A.0 ft re
?-5-7 3t-4 67l 06rt 5�� r�
NC Well Contractor Certification Number :
;i15::0UTEIt'Gr1SING(foi'riiulti?cased;�veIIs�OR�DTNER.(i£apjlicable)'.__�..,• �,'.,;::
Yadkin Well Company, Inc. FROM To DIAMETER TJDCInvESS I MATERIAL
ft. ft. in.
Company Name (1 :15:INNER CASING:OR':1`u9ING:(gent)iermsl:close`d=Ioop)= " . .':s
2.Well Construction Permit#: �l 5 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.rfTC,County,State,Variance,etc.) + I ft. ,/ P ft 6 eD in. DR 411 19116
3.Well Use(check well use): ft. ft. in.
Water Supply Well: o:.17.FgREE�'." .. — `,;_-.- =�=_�- ---
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
• :Agricultural ❑Municipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) ' tesidential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) .his:GROUT.=r"' "•---".-- - `—l"-„--- --`—
❑i igation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 9"' ft 3'en- fis fob-el
OMonitoring DRecovery `t. t p I
�®' f / ®t"yYe6rPdg trod9e3►rel
Injection Well:
ft. ft �
DAquifer Recharge ,❑Groundwater Remediation
1:i19 SAND/GRA.VYZErk. (ifspplic'a•61e)r_-.=_1 __72.1._`` _ as :
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD ' -
:Aquifer Test ❑StormwaterDrainage ft. ft
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal.(Closed Loop) ❑Tracer 211:DRIL1l1YGT;OG'(a"ttaehsddittonilsieeetiii:iiecevary)W ";-`--==_7::1
FROM TO DESCRIPTION(color,hardness,soillroek type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
Date Well Started /0•;5—a /� ? ft 5'�-trt Sol
4.Date Well(s)Completed: f® �c��
•33 Well lD#AA- S<i 5�+'ft ,,ft 'e, /�,rI ,'i/
Sa.WefLocation: Phone#:3 (y °L -�06`� ft. ft ���` �,
a, ¢ fL ft tr.... -i:: �• /--- :.
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Facility/Owner Name I Facility Dail(if applicable) ft. t NOVn i nn•}�
ft. ft N 'r J LInLJ
J41N\sj 22 ( ...Spilt`-N. 1 13'Q ;
Physical ddpressgs,City,and Zip 00 nnccnn ff�t..YYffV�oc ft i11i.,.,:=;r^_v;1 '!--C •.•_ J iJi;;t-_ _
AI
County / Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lot/long is sufficient) c� !� 22.Certification:
-
��a .70s J) NN Cgt° Ito '#"7(' W r . 4'a��',S
.tt.
6.Is(are)the well(s): r:`'ermanent or ❑Temporary Si of C dwell Contractor Date
By signing this fonn,I hereby certify that the well(s)was(were)consavcted in accordance with
7.Is this a repair to an existing well: ❑Yes or YTo 1SANCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is 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. ffr
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
constniction,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.V.)
drilled: v 24.SUBMITTAL INSTRUCTIONS OQ
9.Total well depth below land surface: ;6 (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(4)100')
e 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: �� (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: 0 (m•)BIt Off: 0' 24b.For Injection Wells:Copy td DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
1 12.Well construction method: 6i1 r rD AI." 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 6-.
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FOR WATER SUPPLY'WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611OS
13a.Yield(gpm) /) Method of test: jr 1 a el,
o Date Site Visited:
, 13b.Disinfection type: I U/o hilt Amount: 90 9 Oz Site Visited By: i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018 4:::g
Price: