GW1--03616_Well Construction - GW1_20240613

Vim?L CONSTRUCTION RECORD (GW-1) For Internal Use Only:
• 1.Well Contractor Information: 0
�/ 6 (1)( V V S / it•ur 1, IV)tA Ii/t• / Oil.WATER'ZONES
Well Contractor N e,. FROM TO DESCRIPTION n 1�
L/S 1 b .-,/`/ • �7g ft. _1 E. Ii,ft 3 5 .�i G' wV.
ft, ft. J
ye
NC Well Contractor Certification Number
15:DATERCASING(foimiilii=ca"sed7wellij:ORIMERI(ifap"ticatile);...
Yadkin Well Company, Inc. FROM _ TO /� D TSB CTIHCKNESS MATERIAL
Company Name .� .�L �r` 3 1 ft. 10 Oft C,J in. sop-Z( ITV
c 4
Ow G +( J� //// "q6=IINNERCASING:OR';1'UBING;(ge'�itbermelcclosleedl"oib) . ..
2.Well Construction Permit#: f °-1 T` I FROM _ TO DIAMETER THICKNESS MATERIAL „A
List all applicable well constnution permits l.e.UIC,Coun y,State, Variance,etc) ft. ft. in. �1
3.Well Use(check well use): ft. ft. in.
Water Supply Well: E17'SCREEhY. _
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑`M�unicipal/Public lt,ft. 6 ft in.
❑Geothermal(Heating/Cooling Supply) l esidential Water Supply(single) ft ft in.-
❑Industrial/Commercial ❑Residential Water Supply(shared) .187. ROITT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD A.AMO
Non-Water Supply Well: C. ft. 1.-6 ft. r1,�_„► :le pow C�a�
❑Monitoring DRecovery ft. ft
T1
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
I'll SAND/GRAVEL P.ACIC(if-ip#hcsibh), ;
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMfLACEMENTMETHOD ' •
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology DSubsidence Control ft. ft.
❑Geothermal(Closed Loop) DTracer 20:2)RIIISNGLOG(attach iidditiotial sheen if necessary) .
❑Geothermal ng/C lin Retum Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,sowroek type grain else etc.)
Date Well Started - a 17 - f.v�a o ft ec ft 1,v,e1 �)1
4.Date Well(s)Completed:S''12`"Z. N Well ID#A^ACpp��jj - ` Z (� ft. ft. ,S F re. .1 c�I I
5a.WellLocation: Phone#: 3 -iZY '.34/�+ ft. / 4)0 ft. 1.4ni_/(`Y- ) _ci ttd(he r/
Qclvcr.c to kff 1 140V9v4 Sazi/'A'.
Facility/Owner Name �f / 7 �/Facility lD#(if applicable)p / 76 ft / 9 q ft r-g . 4.we_ �k .4.
,4,vi err-id Act I'c \ /Hv;1IQ ies ft t ;-'eft. ('etl c/-t lJ 4`.I i '' ice
Physical Address,City,and Zip ft. �'V ft. tLi
2I5-TtEM TIKS tf JJ 1 - '!I'A.. �•/
Dov ii t- J I IIV {
County Parcel Identification No,(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: :I;,,ltA
(if well field,one tat/long is sufficient) p 22. I • aI cation: ' -7
7(o. u3a74A9 N Cec.. 67 i6C W plii4 S- ! ( r2 (11
6.Is(are)the well(s): i9i'ermanent or ❑Temporary S e of Certifi Contractor Date
� By signing thisf ,I hereby cert fy tha!the well(s)was(were)constructed in acccrdance with
7.Is this a repair to an existing well: ❑Yes or Li i 15A NCAC 02 .0100 or 15A 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. 1Y
repair under#21 remarks section or on 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 ,fib'
construction,only 1 GV 1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.3 •
drilled: 24.SUBMITTAL INSTRUCTION:? Q
9.Total well depth below land surface: (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3(a)200'and 2©100)
5 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft) Information Processing Unit,1517 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" ,e1
11.Borehole diameter: C... 0 24b.For Injection"Wells: Copy to DWR,Underground Injection Control(IUC)
(in.)
� Blt Off: !T Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: �"� ` (i 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the-
(i.e.auger,rotary,cable,direct pnch etc.) county environmental health department of the county where installed 0
FOR WATER SUPPLY WELLS ONLY: • 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) S -I''' Method of test: C�/ Permit Program,1611 MSC,Raleigh,NC 27699-1611 S • ;r
elvd/^! /
Date Site Visited: ".J=LVh. 3
•
13b.Disinfection type: 7O o�o hth Amount: ` OZ Site Visited By: P rJ C.^ a- +
"- ^arolinaDepartmentofEnvirotunentalQuality-DivisionofWaterResouress Revised6-6-2018
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