GW1--02303_Well Construction - GW1_20240410

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?WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: j ICO
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`. • 1.Well Contractor Information:
Mil/�a'1 ,J _F14S.WA:tatZONES_' "i. -,1:;!:'' .i: 2
. � .dA✓ Ar���/.� FROM TO .••' DESCRIPTION
Well ConhactrorName • �GC) ft. �ft I ' i°
3�d (19 ft, ft
NC Well Contractor Certification Number
Yadkin Well Company, Inc;• ;:is''ova:casnvc'(farms;i1t��esea:�eu�5°:oRz�ER;(;faptii�Ie��: '��:::.'r._.:
FROM .DIAMETER THICKNESS MATERIAL
ft. in.
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CompanyName
1:63I NEICGASING'.OIYTIIEDT.G:(ilitliei lard aerie° • '�.`.:zi ..c:.•,.
2.Well Construction Permit s �� v� FROM TO . DIAMETER MUCHNESS MATERIAL
List all applicable well construction permits Le.UIC County,State,Variance,etc) 4 ft ? ft. in- .64 It 1 i
3.Well Use(check well use): • ft. ft. in
Water Supply Well: rz "v _�z;.,• revr:;: r.-..i;`C?... ':.,,v,- "::..._. ,,`::>'s;,Ito!,i:.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL 4
❑Agricultural ❑Municipal/Public ft. it.
❑Geothermal(Eeating/Cooling Supply) Xitesidential Water Supply(single) ft ,- in. '
❑Industrial/Commetcial ❑Residential Water Supply(shared) i:18 MtbtiT:i s: ,_. ._ ::,;W h:.;1' p. �. 'Y: .,1: � -.
r.r
.❑Irrigation ❑Wells>100,000;GPD .FROM TO MATERIAL • EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. ft 61 (M.d-t ?
❑Monitoring . ❑Recovery ft ft /
Injection Well: • ��/ �/Q
ft. ft.
❑Aquifer Recharge • ❑Groundwater Remediation
1;19::SAND/Qti V.ilMit:ap ii meal's) .,_,. .,. ":,-;r; ‘: `- :::_�,:•:::::` .. ,
DAquifer Storage and Recovery ❑SnlinityBarrier . FROM To MATERIAL .K EMPLACEMENT METHODy
f..
❑Aquifer Test ❑Stormwater Drainage ft ft.
' ❑Experimental Technology • ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20r _.GI;Oa(artliel iiaditlai al."slieets"it'nec-tlsaiy)1 :72.`.::-5
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under#21 Remarks)
FROM TO DESCRDTIOLi(c��or,hardness,soilhacktypegrainalsoetc.)
Date Well Started '3_R3.--., .1 . " 31j ft J'02 ft 6f•an, % -.
4:Date Wells)Completed:' 3-i I-i 1 Well M#A Ae'�0. � ft. • ft ' C.,;.....A.,...'.1._;i 11 K.: N
5a.Well Location: ,, ' -•Phone#:.)163 '®c�, -6l'7eSt] ft, ft APR 1
Ai/LA
y//���//// ® PPP �%°f,' �/j/y ft. ft 0 201.4
•
•Facility/OvmerName FacilityID#(if applicab ft `}k,•,;,•5,,.h , '� J
76(a' S6.:141'
M e ''i- •. !`�,1, • Put lia d'. 'w ft ft /e-Y &CA: disdAir
Physic�allAddress,City and'Zip'
ft. ft. •
dV i 1•k LS i2r?72F1iSttiH`S�' ::y ti ;:_' �`a::7,': ::,:__' ia'T'. . ' t,:c °2.';; :+'s,",'�7
County ` Parcel Identification No.(PIN) j mil/ ' * + ol't`' `le Pt' c�e• oaf
5b.Latitude and loiigifitde in degrees/minutes/seconds or decimal degrees: h° 019 -44. tirt.d,/'
(if well field,one lat/longis'auffieiset) 22.Certification:
h° 1 S/ 17 ' .'_ 8) (2e I 1'6" W .• jam. J -2Y
6.Is(are)the well(s):°Permanent or' ❑Tem orary Sioonahue of Certified Well Contractor Date <
r• By signing this form,l hereby certify that the well(s)was(were)constructed in accordance with S.
�pjs'� ISANC1C 02C.0100 or ISANCAC 02C.0200 Well Construction Standards and that a
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. 7.Is this a repair to an existing well: es or ��il�o p 1copy
If this is a repair,fill Out lolo vn well constrvction'inforhation and explain the nature of the of this record has been provided to the well owner. .13
repair under#21 remark section or on the back of this form. '
23.Site diagram or additional well details: CO
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 ded. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary. 0
drilled: 24.SUBMITTAL INSTRUCTIONS [�
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9.Total well depth below land surface: 3-- "0 / (ff:)
For multiple wells list all depths ifdifferent(example-3Q200'and 2©100) Submit this GW-1 within 30 days of well completion per the following:
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(ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water Ievel below top of casing: Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
(In.)B It Off: 3, 9 V a11.Borehole diameter:
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
/ Program,1636 MSC,Raleigh,NC 27699-1636cA
12.Well construction method: Ai/ . "s Tel/ 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. 'or Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA 11
13a.Yield(gpm) Method of test: /'/K A,l' Permit Program,1611 MSC,Raleigh,NC 27699-1611
70% hth p� Oz Date Site Visited: , - 16 s a El13b.Disinfection type: Amount: L Site Visited By: II k
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources' Revised 6-6-2018
Price: