GW1--07952_Well Construction - GW1_20231208

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.!' ' WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: . ' -
1.Well Contractor Information:
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� 1�4 A/�i/t/ g/"'C� �� t14':WAIF$ZONES•;��::�,.,.,,,.,....._.S':^s _ _-.1.`::_.;-_-•--- -;_
FROM TO DESCRIPTION
Well Contractor Name p�9
-oft. gg. al ft .v."''•
on p� �� 6 it. p qft, ®q
NC Well Contractor r Certification
fi nNumber DTER:CASING(fu"r`multi=casedVas)'ARIA ER-(if:ap.lic`abl'e)'i.=.-..,� r
Yadkin Well Company, Inc. FROM TO .AMrR THICKNESS MATERIAL _3
ft. :L....)
in�Company NameA,� '16:II�TERCASING:ORING(gedtliermil:closed=Ioap]:`T?. ___� L; :,s'f`
2.Well Construction Permit#: +� FROM TO DIAMETER THICKNESS • MATERIAL
List all applicable well construction permits(Le.U County,State,Variance,etc) + 1 ft 9 ft 6 /cl in• e'x)` dy i �8ej
3.Well Use(check well use): ft. ft in. s� I.
F -
v-
Water Supply Well: ,;7:SCItaar .- -::w=_ -- -- -___:"...
FROM TO s DIAMETER -SLOT SITE Till~ S MATERIAL
❑Agricultural ❑Municipal/Public ft ft
❑Geothermal(Heating/Cooling Supply) $esidential Water Supply(single) ft ft in. lA
LA Industrial/Commercial ❑Residential Water Supply(shared) - r- - —-, — ----•:— - ------------- '
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL: EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ® ft. �B ft ,? Id r,, ar/�eg„ �PL�,I, l c
❑Monitoring DRecovery ft t� ft ,J� '� fir/
Injection Well: ft. ft.
❑Aquifer Recharge .❑Groundwater Remediation s-__
i9 SAND./iflAVFS;.PACK'(rf.applicaile)s•,.__,.`-...._:__`=. a_— u. .
❑Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD�
❑Aquifer Test ❑Stormwater Drainage ft fr.�
❑Experimental Technology ❑Subsidence Control • ft /sue �/
0 Geothermal(Closed Loop) ❑Tracer -- ee D311.1 N-.GI:OG'(att hT"sdditional'sheetiiLnecasary)x''" .......1:—J. '`--•
El Geothermal(Heating/Cooling Return) CI Other(explain under#21 Remarks) FROM
TO DESCRIPTION(color,hardness,soNllrec]c type,grain size etc.) .
Date Well Started II 4 7- 3 0 it. F ft. .S
4.Date Well(s)Completed: !l r Ael-al Well ID# ,4p 9/t7 g ft. &i®a„ft //4✓i,%vi. t .-. _
Phone#: 354— 39 r ft ft l� - t,-,,r ' "?'`"t"'�
Sa Well Location: __a
a�
�.S S 6 rn bet I I ft ft P14: �i' 3 21."
Facility/Owneer�Name a FacihttylD#(if applicable) ft. ft.
: � Ou0,44 n sow . R© Lai ANN9 ft ft inlerFr:-yi n P,•..:;..,,,,:rt• AO
Physical Address,City,and Zip NJ g3> 1 ft. ft wi
,"' 4,5 IY 6�' %21;RRMAItics= i;:'._...._..-.,_ -. i',`...rr - G..___.......__>
County Parcel Identification No.(PIN) •
w Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
348 L/ giod 7 N 3/47 144177 W Id- aei.'7' 1.3
6.Is(are)the wags): ermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance with
, 7.Is this a repair to an existing well: ❑Yes or XVo ISANCAC 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 of this record has been provided to the well owner.
ft*, -• repair under#21 remarks section or on the back ofthis form.
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
ti construction,only 1 w 1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
o drilled: 0 24.SUBMITTAL INSTRUCTIONS
1,.Total well depthbelow land surface: I. (R•) Submit this GW-1 within'30•dais of well completion per the following:
For multiple wells list all depths if different(example-3( 200'and 2Q100) 0-'
‘
10..g 24a. For All Wells: Original form to Division of Water Resources (DWR),
If waleatic water Ievel below top of casing: (ft•) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
water level is above casing,use"+"
11.Borehole diameter: 6 (in•)Blt Off: 6.t 6 0°I 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
i
12.Well construction•aiiethod: A.s A re 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(ie•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 DIVE,CCPCUA p
13a.Yield(gpm) I o Permit Program,1611 MSC,Raleigh,NC 27699-1611 t ;
IVlethod of test: / :t.9 or
70% hth 6 Date Site Visited: ' �,;
. 13b.Disinfection type: Amount: Oz Site Visited By: P
tils
Form GW-1 North Carolina Department of Environmental Quality-Division of Water ResourcesRevised 6-6-2018 L /"
Price: ) ' 9