GW1--00764_Well Construction - GW1_20240131

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WELL CONSTRUCTION RECORD(CAW-1) For Internal Use Only: j
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1.Well Contractor Information:�j -�
��1p8 rvl b��n I 1C WATER`ZONESii•'n' :;:d' :=.74,5 `�}n1"gi.t:z;:;: z,; .w ,.:;ia's) 0 -
WellContractorNartle MOM TO DESCRIPTION `jy �,' °
p te.7`3 ft. U'.1)-ft GMQ �-Ccid c 1( 3 V C Pet
-.� A�4 ft. ft ' I
NC Well Contractor Certification Number VI5}:ot R:CASING;(fdi-n.iliVeased: e.ILCORIINERi(ff ip'llaifiilej=;,..`; 12..E
Yadkin Well Company, Inc. PROM TO DIAMETER TEICKNZSS 1 MATERIAL
ft. ft in. g--
CompanyName
:=116i; NNERICASING:OR':TOBINGi a it3iecmaa:elo'sentilijir4 1'�__:�.y:>...:i f
2.Well Construction Permit#: 6 5 tit/ PROM TO DIAMETER ,THICKNESS _ MATERIAL
List all applicable well construction permits(i.e.WC County,State,Variance,etc.) . /� c1 ft ( °G �r� ' SD .tom'2_( PbC
3.Well Use(check well use): [ ft ft I• in.
Water Supply Well: a77 ldfiRIE1r ' . , _.`,.. .::____ _ r _-;'
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft, ft in.
❑Induslrial/Commercial ❑Residential Water Supply(shared) 18iGRo T ' = ,..._`"--�`w= --` -"-----Y`_,4- -.
❑Inigation "". :'"' •i'ii,:...7 lWells>100,000 GPD PROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well L..-n n4 II-,a".'° 0
ft ft p
❑Monitoring Jai , -r') ❑Recovery ft. ft.
Injection Well: i' `' it ft.
❑Aquifer Recharge ,,,_ �.n('14iGroundwaterRemediation __-__
^1 ifliYSAND/GR'AVF PAGIC(if applicable)';": - _ ___
❑Aquifer Sto 'Vi ry ty • '
�dgeand�ecoV.e ,�� ❑Salmi Barber FROM TO MATERIAL ^� EMPLACEMENTMETHOD�'�_�
DAquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control ft. ft -
❑Geothermal(Closed Loop) OTracer 2d;DR1ltrt4G?LOG.`(atfiaiT dili'a"na'lilikiiiiifiaece"sseiy)°:1117.-_ w1
0 Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/roartype grain size,etc.)
Date Well Started//Ae -t s 734 0 ft as-'ft S °/
4.Date Well(s).Completed:1 .3 Well ID# • "' , - si ft Irg,'ft ill,$/ / ie®
Sa Well Location: Phone#: 's 7 , 3 re ft. 7 3:ft j / cid /fey �ne
p e ft ft -
Da'"i 1-�" �®Pt� vie _ .
Facility/Owner Name Facility ID#(if applicable) ft ft '
' �a es/�d, �, ft ft .
s°� l' ft. ft
Physical Address,City,and Zip `T'r„ 61k` i Ncsi�� ,
County Parcel Identification No.(PIN) • g g_ a 6
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: C-f �` }�����®,
(if well field,)one latllllong1is sufficient) 22.Certification: % �p
. 3c "G/e CPC. Q3 N El 0i Y5-c w lif % . Ir '�9''
Si.4.' ofCe's red Well Contractor:• Date
6.Is(are)the well(s): j Permanent or ❑Temporary r
f 13y signing this form,Thereby car*that the we (s)was(were)cotsrrracted in accordance with C
7.Is this a repair to an existing well: ❑Yes or to 1SANCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction S that
tandards and at 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 remarks section or on the back of this 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 67.
construction,only 1 GW11 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary. -)
drilled: 24.SUBMITTAL INSTRUCTIONS v=
9.Total well depth below land surface: 7 . (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q200'and 2®100)
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: 6 (in.)Bit Off: 6.//s® 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IQC)
Program,1636 MSC,Raleigh,NC;27699-1636
12.Well construction method: it O i:f'1.V 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(um) �� Method of test: fro
Date Site Visited: �0
e hthd 'r �
13b.Disinfection type: 70�o Amount: 9 I OZ Site Visited By: . C"'
s�'.
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Form GW-1 „a __,,___ _ ,._Nortb.CarolinaDeoartment of Environmental Quality-Division of Water Resource's Revised 6-6-2018