GW1--07949_Well Construction - GW1_20231208

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: U3
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1.Well Contractor Information: al
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Well Contractor N FROM TO DESCRIPTION
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NC Well Contractor Certification Number 713:OIITER:CASING`(fo'rmrilti=ciised_" )':OR7OMit':a`.lic'shle).. :'.aj i"ter ice:
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS 1 MATERIAL
ft. ft , in. a
CompenyName C>:e"; :... :. "=�
y� �J `trEINNE.RG'ASING:OR:lu.ti1NG(adthelialeloieniiiru)� 1ZY-"-.. X.
2.Well Constraction Permit#: PETS A � �� ° g FROM ft TO ft DIAIIIETER m THICKNESS MATERIAL `.n
List.all applicable well construction permits(i.e. IIC County,State,Yaricmceetc..) *1 __ d/1_ _ Ln1 __-___,$,o C.A _ po4._
3.Well Use(check well use): ft ft in. n
Water Supply Well: n._v..___�___. _-.w._.-_-.,
FROM TO DIAMETER SLOT CTZR THICKNESS MATERIAL
❑Agricultural ❑M��unicipalPublic f. ft. in. '"�
❑Geothermal(Heating/Cooling Supply) [R3Cesidential Water Supply(single) ft ft in. 3
❑Industrial/Commercial ❑Residential Water Supply(shared) 18vott0 c - ,w...; .
. ..,, --- Y .___-- --------_------:--_=
❑Irrigation ❑Wells>100,000 GPD FROM TO lsMATERIAL EMPLACEMENTM IIIOD&AMOUNT
Non-Water Supply Well: 0 ft ft. ec.�-c.. �a"eV
❑Monitoring ❑Recovery ft. al ft
Injection.Well: ft. ��°9i1���q i�a�o
ft 11
❑Aquifer Recharge .0 Groundwater Remediation _.__
ral••T5'A�`ID/GR'AVS�L ACmtifilc cable)'.;- - -----__.__ ___....i•tti.
❑Aquifer Storage and Recovery ❑SalinityBarrier FROM TO MATERIAL EMPLACEMENTMETROD .
❑Aquifer Test ❑StommwaterDrainage ft. • ft.
❑FxperimentalTechnology 0 Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer :20'sDRi SPIGZAG;(attachidditliF '"sheetaifneeleil 'Z„"--_--
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness;soil/rack type,grain size,etc.)
Date Well Started /d-I ? 0 ft 3`ft. 401 "/, . 9 I et�_4k'
4.Date Well(s)Completed: O I-f 1 z 4:0'3 Well ID# 'O 8 1 '„?g ft ° ft. ®T/ k 4.. 4®tiov .1v.9'
5a WellLoca1ion: Phone#:'2g- d�'.r` 0 ft ft
• •0.,1' i, T w i€. ft. ft. :
n�� S Reater P M E 1-LC. . - t� t .. . ;r -
Facility/Owner Name Faeility Mit(if applicable) ft. f
A�, Cl7.5' C t'� e 1.-ea ke-12-1 t 't..�1*A. ft ft. L1►-I,. U 8 2�L r�
Physical Address,City,and.Zip f
�° t ft
ir/1� 1DZ�J :gar°>miza,rs � ~.�-== .. T;• ,„ ---v
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County Parcel IdentificationNo.(PIN)
Sb.Latitude and Iongitude in degrees/minutes/seconds or decimal degrees: .
(if well field,one lat/long is sufficient) 22.Certification:
35.g511b30 N —%.4n14110CI`I W / .
6.Is(are)the wags): C Permanent or ❑Temporary Si of ertid ell Contractor Date
� By sighing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or Q1Yo 15ANCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and explain the nature ofthe ofthls record has been provided to the well owner. C
- repair under#21 remarks section or on the back of this form. ,�jy,
23.Site diagram or additional well details: 77"
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the bark of this page to provide additional well construction info
construction,only 1 GW=1 ins needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also attach additional pages if necessary.
drilled: y 24.SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: ®ram (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@l00)
1.0.Static water level below top of casing: e9-® (ft) 24a. Far All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1.617 MSC,Raleigh,NC 27699-1617
ifwater level is above casing,use"+"
11.Borehole diameter: CP (in.)B it Off: p- il®As 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: A:0-go'i ai 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the 1
(ie.auger,rotary,cable,direct push,etc.) county environmental health department of the county-where installed re
FOR WATER SUPPLY WELLS ONLY: U
24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
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Method of test: - o �� Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) . �((
If Date Site Visited: %/,2,"23
. 13b.Disinfection type: ��c�o hth Amount: A,J o OZ Site Visited By: 13
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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