GW1--01622_Well Construction - GW1_20240313

WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only: ,
1.Well Contractor Information:
/ " ` i 111-" C61144' E 4:,WATER'ZONES' ._..,:4- &-tc,:Di. .. :�::-,.1"-,•:2 ;J,: ... ., •.. .
FROM TO DESCRIPTION
Well Contractor Name
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ta0 ft. II'cit. �,�Oyt 631v6t 4 roc I
`` (� l`]? ft If v ft S,Q,., far rpm k
NC Well Contractor Certification Number :;15:OUT1;Rt. SING`(fonmulti=eilStd:wells)•:ORTa1ER,{➢fii`liealile))---:::•.?:_ :•"
Yadkin Well Company, Inc. FROM TO DIAMETER THICRNFSS MATERIAL
ft. ft. • in.
CompanyName , �,1:- ,.�:.-.
c 2 A i16lINNER:CASING'OR'1'UB1NG;{(eotbermal'dosed=lfiop)1:::��
2.Well Construction Permit#: ev2f 1 tU FROM TO DIAMETER THICKNESS
List all applicable well construction permits(IA UIC,County,Stale,Variance,etc) + B ft. 8411
4ft /'-f l-in IQ/� 1 j �L
3.Well Use(check well use): II ft ft (� J in P��J-
= ^
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
)Agricultural ❑Municipal/Public ft ft. in.
0 Geothermal(Heating/Cooling Supply) 30.esidential Water Supply(single) ft ft in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18 G1tbUTE : "2 "----.---7-:.----_'_ -_ --_-_-_---.7. e_ 77:
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❑b ❑rigation Wells>100,000 GPD FROM TO liATER1AL EMPLACEMENT METHOD&AMOpNT
Non-Water Supply Well: 0 ft. a.r ft Bill 71 C-I;I e C, .D ! 6 ttceo
❑Monitoring . ❑Recovery ft. • ft ;a . ' l t P
Injection Well: ft ft / S
❑Aquifer Recharge ❑Groundwater Remediation �
1519`SAND/GRAVHL•PACK'(if applicable)' W_ _ __aKE- :'.sue-i.__. .,o..i_,-rF--':."�''
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTI ETHGDt 'er 1,-,LA'
❑Aquifer Test ❑Stormwater Drainage ft. ft M'a't n 1 .
1
❑Experimental Technology ❑Subsidence Control ft ft a t t�i2
❑Geothermal(Closed Loop) OTracer :20e1iR)ALINGI:OG'{atlacti`adaitional`sheeti id:necrTsary)R y;,::•,•�;�io`,.�,I,2 lsh
FROM TO DESCRIPTION'(cola,hardness,ieitrock ty'p" ';lu,'eti.),""•a
❑Geothermal(Heating/Cooling•Retum) ❑Other(explainunder#21Remarks) ® ft xi it Y° ' '`'�"
Date Well Started f). 'a- 3 /{ �J So;1
4.Date Well(s)Completed: 1-)-' .9 Well ID#AA P® &s- t'( ft. 6' ft. .5 pc..4 t 1 t
Phone#: ga � 43I S" /� q
SaWellLoca�tilon:/ 7� ft 3 p ft ; Sdt '
�R4/�1� [�' fZ$' �L9/A,��f ey +i /irn"sy tiv ) ft. S� ft M � ' 1rrnFacility/Owner Name y acdD#(if apphcable) g�� 6 ft 6 a ft 5i'w" 1 rAG 7u'' 1 Vci it
t ei 7() Nc Is/wi aos - 4l, Boa', amor ft. Po ft. Mtn . ,rµ7 5.f AAjLf
Physical Address,City,and Zip I�� ft �:1 s ft L Lfrgi1vA lr ('\ LA-fat-1 L
21REMAR'KS1",w; -____... _...— - .?County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: !Wei LI`t S?+ OI t 1�IJr
(if well field,one 1at/long is sufLcient) 22.Certification:
3GB ) 71I, N 3-1e .7779g w , E—C l" 9 "a "
6.Is(are)the well(s): 'ermanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certi6,that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or )I to 15ANCAC 02C.0100 or 1541 NC/IC 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 remarks section or an 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
construction,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.
drilled: 3 24.SUBMITTAL INSTRUCTIONS
ii
9.Total well depth below land surface: LIal t (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3 r@200'add2@100)
f
10.Static water level below top of casing: 1[/d (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+" /' Information Processing Unit,1617 MSC,Raleigh,NC 27 699-1617
11.Borehole diameter: C., (in.)Bit Off: ‘1 I IDS- 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636 t •
12.Well construction method: coc 4o I l -g,At g� 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) l/ county environmental health department of the county where installed e
FOR WATER SUPPLY WELLS ONLY: • 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
.13a.Yield(gpm)
i
1Vlethad oftest: Permit Program,1611 MSC,Raleigh,NC 27699-1611
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70% hth Date Site Visited: i .
13b.Disinfection type: ,Amount: • , 11 OZ Site Visited By: I I
' Form GW-1 .North Carolina Department of Environmental Quality-Division of Water Resources _. ' . Revised 6-6-2018 Zr''
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