GW1--00761_Well Construction - GW1_20240131

. LL CONSTRUCTION RECORD GW-1 For Internal Use Only:
1.Well Contractor Information:
MAW Cla V ...P3116 FR WATERZONES :_ -___ .._
FROM TO DESCRIPTION
Well ContractorrName
C ft. ft lute. ea('�uf�,
�J ITV ft ft
15:O1T1 CASING(foir•'mniti=eesed:welli)'ORLINFdf(if:'a`livable)% ' .
NC Well Contractor Certification Number THICKNESS MATERIAL
FROM I TO I DIAMETER - ^
Yadkin Well Company, Inc. ft ft in.
Company Name :16.1NNIRCASINGORTUBING`(gicitl etmal.dos`ed=luop)•s-'=------- -
D 2D�3 FROM TO DIAMETER THICKNESS MATERIAL
Li Well Construction Permitcon s 1. �� .r�-p ftft ® s' in- ; 165 L:fa,W Val i�Ze-t
List all applicable well construction permits�.e.U1C,Comity,State Variance,etc) _ I t 7S L
ft ft in.
3.Well Use(check well use): aalata FiPZ1 , - -- - -- -- - -- ---- -,
Water Supply Welk FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Municipal/Public ft ft In.
❑Agricultural ,"
❑Geothermal(Heating/Cooling Supply) liesidential Water Supply(single) ft ft ill.
❑Industrial/Commercial ❑Residential Water Supply(shared) „18E agO11T
❑o ❑Wells?100,000 GPD FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well:, - ,r ;_ _... t` '.-.-., ft, 6 ftVeVILdhA q fay i)-l--
❑Monitoring ❑Recovery ft. ft.
Injection Well: JAN S 1 CUL4 " ft. ft
❑Groundwater Remediation •""
❑Aquifer Recharge i 19.SAND/GRAVES PAC&(if applicable)i- - -- . ._
-1:.:.
❑Aquifer Storageand;Reoove"ry' �'', :"may',❑SahmtyBarrier FROM TO MATERIAI. EMPLAc�vDsNTMETHOD
❑Aquifer Test ❑Stormwater Drainage
pExperimental Technology
❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) OTracer -20.DRICI NGLOG(attach udditlonal slieetiif eves fi y) .__ she,em
FROM TO DESCRIPTION(calor,hardness,sail/rock type,grain )
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft.Date
ft. 5th g
Date Well Started i 2- 7- 2 3 q 1P' 9'0c r•9- ft. tod ft. C. k
4.Date Well(s)Completed:g 2� `Z 3� Well ID �3C�
0
Phone#: 33 qCS- t'7'I-K ft j3 rt G 1 C 1 bri ire
5a Well Location: �'� ft. ft. ��� ��� �C�L t=
R g
filar(/ame li/��f'' t/ ft �1 ft /- u.�e (,&tl c$ Q .
Facility ID#(if applicable) ca ' pL�� �1 Cti1 C '�7" ��
Facility/OwnerName] �j ( � A /�
a^6 c 3 l i,A c..e.)e- I 1J`yu.o� (yi'ASC/ ft. ft
ft. ft
Physical Ad e s,City,and Zip �,J V a gf�. 21nnPLI4fAFRfi - -
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Certification:
(if well field,one lat/long is sufficient) „
3C , �`1s3-1=N ,•e', I
Si a of e[tified Will-Contractor Date
6.Is(are)the well(s): Direermanent or ❑Temporary
By signing thisfonn,I hereby cer*that the well(s)was(were)conshucted in accordance with
•
La]1
7.Is this a repair to an existing well: ❑Yes or o 15A NCAC 02C.0100 or 15ANCAC 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.
repair under#21 remarix section or on the back of this farm. 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
construction,only 1�rW 1 is needed. Indicate TOTAL NUMBER of wells
(add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: �/ !� i 24.SUBMITTAL INSTRUCTIONS
It 9.Total well depth below land surface: d�"1 (ft') Submit this GW-1within 30 days of well completion per the following:
1I For multiple wells list all depths if different,(example-3(g12000'and 2®100)
5'�% ( ) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 5'l% ft" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use•'+" / y
.+�J 24b•For Inieca_ 'on Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.)Bit Off: 6' Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Ate ory 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
FOR WATER SUPPLY'WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) fi Method of test: r Date Site Visited:f® •'27-2.3 e °dun
011 6a� we. a
13b.Disinfection type:
70% hth Amount: OZ Site Visited By: O In. .
North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018 i
Price' VN NI Rfr
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