GW1--02295_Well Construction - GW1_20240410

r wELL CONSTRUCTION RECORD (GW-11 For Internal Use Only:
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1.Well Contractor Infogrmaation: p�,,,�
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Well Contractor Name FROM TO D CRIPTION
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NC Well Contractor Certification Number 115 VAS
.0UT :mIliOVoi• rilti=csse'3:iiells):ORLINER'if s�'livable) .'..?Za k-
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS .',MATERIALS
ft. . ft. '•,
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CompanyName tNISgg,®® r
�°'�aaY������®�� I16F`INNF.RCASIl`IG:OR.TUBING:(gentbermal.elan`ed=1o'op)7..::L_>= 2:11:=:/:
Y�6 2.Well Construction Permit#. FROM TO DIAMETER THICKNESS rkTERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) +1 ft p,,`,f ft UK in. 5DR�i (I o
3.Well Use(check well use): . ft 7 ft in. !!! (/
Water Supply Well ;`1.7 1SCR1 T._ - ---_`�:-=:'°_:�... -• -._._-� -`�_"...�.
FROM TO DIAMETER SLOT Sr7.i+ THICKNESS MATERIAL
❑Agricultural D-MMJunicipal/Public ft ft in: '
❑Geothermal(Heating/Cooling Supply) lBResidential Water Supply(single) ft ft in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) !y _e_______ -_ y_.
❑laigation ❑Wells>100,000 GPD FROM TO Y MATERIAL EMPLACEMENTMETHOD&AMOTJNT
Nan-Water Supply Well: ° ft' ftark‘CAaT C ll)/ a i
❑Monitoring DRecovery ft. ft.
Injection Well:
ft. ' ft. '
DAquifer Recharge ❑Groundwater Remediation ___ _
t`].9::SAND%GRAIEL;PACK'(ifiipplic`alile)r -�.' -1
DAquifer Storage and Recovery ❑Saliniity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test ❑Stormwater Drainage , ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer 20DR1);7ING'IAG;(atfa'ch additional`sheeta'ifneceuary)`, ;.`_<_
FROM TO DESCRIPTION(color,hardness,sallhack type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks)
Date Well Started.;," 21.9 b ft. gs ft. ra 11 ,
4.Date Well(s)Completedd "3-ell Well ID#, A P-q?7 a<S ft. 3.1 ft 1. c 6'ry
. 5a..WellLocatiioon .; . Phone#: - t�`�a• 2 �� ft Aft
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/ / ►1tke-�.rott5p[A(r1 ft O� ft F� "ry sJT®,' ,ry •
- Facility/Owner Name -' FacilityID#(ifapplicable) ft ,
Y-3•�! 1 ooi r. -- f • r,d, (410 ft - ft ' APR 1 :4:.[0�4
Physical Address,City,and Zip ft. ft. '
County Parcel Identification No.(PIN) • .
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one 1aUlong is sufficient) 22.Certification:
Z,Y 3J-1 N Vie. ‘..8-1 �'0 w ` ®-� aiA
6.Is(are)the wel(s): f�ermanent or ❑Temporary ignature o ertified Well Contactor Aare
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with ,
•• 7.-Is this a repair to an existing well: ❑Yes or Rio o • 15A NCAC 02C.0100 or 1SA 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. -
repair under#21 remarks section or on the back of this form. CA
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 .00
(add'See Over'in Remarks Box).You may also attach additional pages if necessary.
construction;only 1 GW 1 is needed. Indicate TOTAL NUMBER of wells
drilled: "''' '• ' '
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: e/ (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 2Q100)
10.Static water level below top of casing: /� (ft) 24a. For All Wells: Original forth to Division of Water Resources (DWR),
"�+"a' Information Processing Unit,1617 MSC,Raleigh,NC 276994617
If water level is above casing,use" I
11.Borehole diameter: lJ' (tn, 00 3 24b.For Injection Wells: Copy to;DWR,Underground Injection Control(IUC)
Cm.)Bit Off; ( Program,1636 MSC,Raleigh,NC 27699-1636 1.33
12.Well construction method: rill 1 CL"9 fy24c.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
I.
ro
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA -N
D t� 1`1 Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 4 ` Method of test: ✓ I i Av. a...r (,
a Date Site Visited:C-23-21 R ;
13b.Disinfection type: 7O/o hth OZ Site Visited Adu3-11
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• Amount: B Y A I 0
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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