GW1--03273_Well Construction - GW1_20240528

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: 3
1.Well Contra at Information: 0)
AII�4-G^ L CeN V t ...14.WATER ZONES
FROM TO DESCRIPTION
Well ContractorNtime
[- J 7 S'Gft. 35 i ft. t� 3,,,,1 • 3 I/
s-
3) `� 3C?". ?if ft. /G C,
NC Well Contractor Certification Number 15.OUTER CASING(for multi-tas,Ds)OR LINER(If ap 'Suable)
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS 1 MATERIAL
ft. ft. in. �•L�
Company Name q / 16.INNER CASING OR 1 UBING Wither mal elosed-loop)
).
2.Well Construction Permit#: d 4►" iii FROM TO DIAMETEF_ THICKNESS MATE PIAL
,_ ' 2So (3(a��IC �� (
List all applicable well construction pnnri[s(Li.LB County,State Yarimtee,eft) i t ft. I a.". 's lr*
a
ft. ft ht.
3.Well Use(check well use): _
Water Supply .F7.SCREEN. _
pp y Well: IZ
FROM TO DIAMETER SLOT SE THICKNESS MATERIAL t:
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ( tesidential Water Supply(single) ft. ft. in.
DIndustriallCommercial ❑Residential Water Supply(shared) is.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT/ METHOD&AMOUNT
Non-Water Supply Well: 0 ft g L ft �e/) 1-..4,ft LL a P1 PI *01
DMonitoring ❑Recovery ft. ft. �� l9� S S
Injection Well: n, ft.
❑Aquifer Recharge ❑Groundwater Remediation SAND/GRAVEL PACK(if applica]de
DAquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL` EMPLACEMENT METHOD '
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRItLINGLOG(attach additional sheets if necessary)
FROM TO DESCRIP1I0'9(color,hardness soil/rock type,grain size,etc.)
°Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
Date Well Started 1 j —?I,{ e , ftj -,11ftSepw"l. cAft �, ,�°G/4.Date Well(s)Completed:Il '— f"2f Well ID# /- y ?• , [,a ft. ! 7Ul ft. fi ro. p"t' ,u 1)�.,
411
5a.Well Location: Phone#: 33 -2 0 -3..�'7% t 3v ft. t 3 2 ft 6!�ra Ji / /6 C /\ I
Vim di8 / M$L'a r� ,J�e7fc `6 ! ft. 5aF/.L 5rG7 ` f-6/1eI-
Facility/Ow�neer Name
/ /p�,� Facility ID#(if applicable) j ' L . Li�,� Ai 7N.— �ei 7 y!G/1 t f I
3 O f Co/o�t-L L " K/ f t (��`11./ke ep t ft. ft.
Physical Address,City,and Zip a t/► �lt , ft. ft.
i • 21.REMARKS
A�s4.k, _
•
County - Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ^- 1/Lt/1 C A 5 Cfr, `t ALA
(if well field,one llat/1oo/ng is sufficient) 22.Certification: `
4 ` 7, 3o# ?i 4.i. I. P'r W ,„ ,•,c 4 -4,2 `�}---2Li -_
6.Is(are)the well(s): Crermanent or OTemporary Signature of Certified Well Contractor Data
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 I'Io ISA NCAC 02C.0100 or ISA NCAC 02C..0200 Well Construction Standards and that a copy
lv
If this is a repair,fill out known well construction information an explain the nature of the of this record has been provided to the well owner. 0)
repair under#21 remarks section or an the back of this form. 23.Site diagram or additional well details: u`
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: t, 24.SUBMITTAL INSTRUCTIONS LA
9.Total well depth below land surface: 4 9.2 (ft.) N
For multiple wells list all depths if different(example-3Q200'and 2Q100) Submit this GW-1 within 30 days of well completion per the following:
124a. For All Wells: Original form to Division of Water Resources (DWR), ro
10.Static water level below top of casing: at) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing use"+" 4-r
(,� (in.)Bit Off: -Jig 5-5 24b.For Injection Wells:Copy tc DWR,Underground Injection Control(TUC)11.Borehole diameter: Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 1,-11-4 ey 24c.For Water Supply and Open-Le op 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 aver 100,000 GPD: Copy to DWR,CCPCUA
1 Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) tT/ Method of test: -, o-r'-
o Date Site Visited: 13' ....3
13b.Disinfection type: 70�o hth Amount: l� oz Site Visited By: lc i `` ©/
5,, 14. i � l.L e✓�'�1 r W a.+ c' Revised 6-6-2018
ra....t.r..,.lu,,n'nartment of Environmental Quality-Division of a ResoWi