GW1--04302_Well Construction - GW1_20240722

WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only:
1.Well Contractor Information:
l
I) 4-144-k„f ms i)i4:WATEZtZONES` ::'=eii .
FROM TO DESCRIPTION
Well Contractor Name /.
a 5 f.Q 38 ft. y a o ft- 2 PM
138 ft. 145 ft 38 6961.1
NC Well Contractor Certification Number ;:15.`OUTEIt;CASING'(f6i iiiiilti'cased'weIIa)':ORZ INE.R(if ap lic`itil ::
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS 1 MATERIAL
ft. ft in.
Company Name LI�y ^ ,....--
FROM` 14.16 IlVNER,CASING:ORl UBING_(ge itbei mad do'iedloop)' .
2.Well Construction Permit#: 0 ) I -�✓ TO DIAMEIrl� 'ri�clavlrss MATERIAL
List all applicable well construction permits(i.e.UIG County,State, Variance,etc.) ' 1 ft. 30 ft Gl/y in. spa^ 1 Q J `
3.Well Use(check well use): ft. ft in .iV+�s r
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaliPublic ft. ft. in.
aft ' ❑Geothermal(Heating/Cooling Supply) 'Zesidential Water Supply(single) ft. ft. in.
_ ❑Indush-iallCommercial ❑Residential Water Supply(shared) '18"GROUT::'. :-'
,S"i ❑hrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: C) ft. 5 ft. KOtjf Pius payed .5 ,a5S
1 ❑Monitoring ❑Recovery S ft. as ft p GNd PvvwC 3 b65S'
4a, Injection Well: ft, ft.
'w ❑Aquifer Recharge ❑Groundwater Remediation
""J .'1'19.SAKI)%QR'AY.EI:P.ACK'(i - . . . ".
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD '
....,ti ❑Aquifer Test ❑StormwaterDrainage ft. ft Lj ❑- Experimental Technology ❑Subsidence Control ft. ft. -
c....
® El- Geothennal(Closed op) ❑Tracer '20:DRI)_fNGIOG(attic)),additi'o"n'a1sheetiinecesiary).' -
❑Geothermal(Heating/Cool g R ) ❑Other(explain under#21 Remarks) FROM _ TO DESCRIPTION(color,hardness,soilirock type,grain size,etc.)
'j I 2 ft.
„ 1
_ 4.Date
Date Well Started 3 ZM ft. 2 2 V /�
Well(s)Completed: S ' 8ay Well ID#..A IS. I 2. ai ft. 182ft V(cLn,i.1
N 5a.Well Location: Phone#:J i c- 4410-- gNio ft. ft. `llni
J ft. ft, _ . -.
II( * s •.
Owner Name Facil ty ID#(if applicable) ft ft E��ti--�.A L. •'.r Li
tl .(3 C VLF'+ / 11 Ct 4/jk WWftnSvill, ft. ft JI)I 2 2 ?0?4
Physical Address,City,and Zip �/(� / 3 ft. ft
/� 4`3. i 1.21*"RRMARKs. . ..:.5..°Ja..i 3:3'Y
1'I$I1di Df, r..4'i �i
County Parcel Identification No.(PIN) 7
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one laUlong is sufficient) 22.Certification:
3(s,, Lj( y ifI N 8 1 , 3 7 6 6o w
6.Is(are)the well(s): Permanent or ❑Temporary
Sign of Certifed Well Contractor Date
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 KNo ISA NCAC 02C.0100 or ISA NCAC DC.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature cf the of this record has been provided to the well owner.
repair under#2I remarla section or on the back of this form.
23.Site diagram or additional well details:
S.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: 1 24.SUBMITTAL INSTRUCTIONS
p
1
9.Total well depth below land surface: 8� (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2Q100')
/0 (ft 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use'4"
11.Borehole diameter: C. (in.)Bit Off: S,910 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,I636 MSC,Raleigh,NC 27699-1636
,
12.Well construction method: La/! lt)'*f4 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) 7 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
13a.Yield(gpm) 4o
t
Method of test: !�`�� ei/1 ° Permit Program,1611 MSC,Raleigh,NC 27699-1611
70% hth • Date Site Visited: If - / - 29
13b.Disinfection type: Amount: oZ Site Visited By: frjr3
P.m-mow-1 North Carolina Department ofBnvironmental Quality-Division of Water Resources Revised 6-6-2015
Price:_ - ,