GW1--03251_Well Construction - GW1_20240528

- WELL'CONSTRUCTION RECORD (GW-1) For Internal Use Only: (-_-___
1.Well Contractor Information:)-0 y L 1 I II-
t f\/')
Lot 1 Vs 3'7r A:WA1UZONKS
FROM TO DESCRIPTION
/� Well Contractor Name _
ft. ft
[o ., c� y 10 �,�v
ft. ��U ft S N
�� NC Well Contractor Certification Number ';1-5.'OUTER CASING(foi malti*ii *ells :ORLTNER:(if17;11 a1 4-:: CA
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name ft. 8 U ft [•12 S in. ��-2' PVC liP
c, 16 ,CASINO -Gl'OR.rUBvING6(eoffier'mi elOied=oop)`
P2.Well Constriction Permit#: (/4 �`��. CO C 7 a FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(le UIC,County,State,Variance,etc) ft. ft in.
3.Well Use(check well use): ft. ft in.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
[Agricultural ❑Municipal/Public ft. ft in-
❑Geothermal(Heating/Cooling Supply) 114fresidential Water Supply(single) ft ft in.
['Industrial/Commercial ❑Residential Water Supply(shared) ... s y
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: /1 ft. /L 9 ft. a- _ ,Ft 1 :P C p&' Zt'A.,
❑Monitoring ❑Recovery lJ ft. ft /�r Gh �! 1 ✓
Injection Well: —'
ft. ft
['Aquifer Recharge ❑Groundwater Remediation _
1.19.SAND/GRAVEBEACK(rfnppliClili e)1''r:.. `'
DAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test ❑Stormwater Drainage ft. ft.
DExperimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer ,.20iDRITLINGLOG(atria iddiHonal`sheets if nec'essafy),'':.',.:1
❑Geothermal(Heating/Cooling Return) ['Other(explain under#21 Remarks) FROM TO DESCRII'TION(color,hardness,solllraek type,grain size,ate)
Date Well Started 6 s -01 - Z4 !/ 0 ft. 30 ft c'k�
4.Date Well(s)Completed: OS •113.24 Well ID At .- `/ /r' 3 1 ft 6 S R Gaa.a Vt..k Dry 4
5a.Well Location: Phone#: 3 'f'"�� -+r3 S 6 6 ft. 7 f ft s d 1' � ri,
Te L
�S�P�Toy C t' 7 ft. Q ft nGV'e� rQ,ry f Q ` {,.r - `-.7-
Facility/Owner Name Facility ID#(if applicable) 3 s ft. 9 S ft. rat. It
"/ q 7 ft L9U ft %"it.+e MAY rl? "'
Physical Address,City,and Zip t 6� 1I'7f�1t t 01 ft Z a b ft ra"1/t `
,Su r r /Ol I l v • .21 iT2EMARICS.' • ..:, b: Y
County I Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22, rtifrcati n:
gr., 41,3"06 s- N
80, 44476 ` S- W A� o S '0 3 -2t1
6.Is(are)the well(s): BYermanent or ❑Temporary Si tort of C ed Well Contractor Date
By signing t form,I hereby cdrtify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: [Wes or o ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy y
If this is a repair,fill out knownwell construction it formation 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: - `r
.-i
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this pageto provide additional well construction info -�_,
(add'See Over'in Remarks Box).You may also attach additional pages if necessary.
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wellst`�
drilled: I 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Z 2-6 (ft.) -
For multiple wells list all depths if different(example-3@200'and 2Q100) Submit this GW-1 within 30 days of well completion per the following:
(/ 24a. For All Wells: Original for m 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.)B It Off:
6 . 0 6 5 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
QQ Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Air44-07 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) 5 Method of test: �4 r Date Site Visited: 3-2 7- 24
0
13b.Disinfection type: 70�0 hth Amount: ' OZ Site Visited By:_ )175
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018