GW1--04339_Well Construction - GW1_20240722

Wn��� 'ONSTRUCTION RECORD (GW-11 For Internal Use Only:
1.Well Contractor Initformation: 1I�`
u'X4.WATER ZONES
FROM TO DES
` Well contracto'N;une Z ft. %% & Zia""
n
-1 0 3 6 A 10 ft A, f`.
NC Well Contractor Certification Number 15.OUTER CASING for muiti=eased wells OR LINER if ap livable
Yadkin Well Company, Inc. FROM TO ♦MET1R ICON Ss MATERIAL
Company Name 16.INNER CASING OR TUBING "i'6th6inal closed400
FROM TO DIAMETIM THICKNESS MATERIAL
2.Well Construction Permit#: O�1_►V l�C ©U in A� ft. ft ,3 !�L �L P@( sly
List all applicable well construction permits(Le.UIC,Comuy,State,Yariance,etc.)
f[. ft in. y UPS►C 3�9 /�
3.Well Use(check well use): —
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic ft. ft in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) tt in
❑lndustrial/Commercial ❑R/�Ie�sidential Water Supply(shared) 18 GROUT
WC-lls>100,000 GPD FROM TO MATERIAL EMPLACEN1TTTr METHOD&AMOUNT
❑lm ationft. 3 fL / S
Non-Water Supply Well:
❑Monitoring ❑Recovery ft, ft.
Injection Well: ft.
❑Aquifer Recharge ❑Groundwater Remediation
i 19.SAND/GRAVEL PAGI{if a' livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMFIVTMETHOD .
❑Aquifer Test ❑Stormwater Drainage
ft. ft ill
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer o.DRMLBGLOG attach additional sbeets if necessary)
FROM TO DESCREPIION(co r hardness,soillrock e, n size,ttc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarksii ft fL i
F
Date Well Started A 40
4.Date Well(s)Comp leted:H'��' �y Well / S ft' T2— it, wttti�
Phone#: - 3 it 3.-b ic. �, �� _ S�'�t� Mad ..✓ r.c< s
5a.Well Location: ra Q.! e
Xn:fga L Lk A" ft. ft.
Facilitya C
f Facility/0 rNamc ID# if( applicable)
ft ft r k`'
�i�t� � 7�'`-�•-N ft ft. _'i 2 L
Pbysical Address,City,and Zip e
(/� ,,y/,�� 1 O -- 21.REMARKS_
l'r-(A1, \O r 1_
Qf7
County Parcel Identification No.(P1N)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Mlong is sufficient) p / 22.Certification:
�Z t©'2 N 1 . �� �a,3 W 7oZ0, �_z�,1� y- '
Signature of Certified Well Contractor Date
6.Is(are)the well(s): 24manent or ❑Temporary
1 By signing this form,I hereby cerkfy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 34 15A NCAC 01C.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a copy
If this is a repair,fill out brown well construction information 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:
You may use the back of this page to provide additional well construction info
construction,only
1 o
8.For Geo G (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
, 1 G;-1 is needed. Indicate TOTAL NUMBER of wells°r Closed-Loop Geothermal Wells having the same
drilled: 24.SUBMITTAL INSTRUCT[ONS
(�
9.Total well depth below land surface: 6 /d% (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)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 30 , (ft•) Information Processing Unit,lb 17 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+';J�ry +�p 6 I f
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: Qn•)Bit Off: Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: G+ ,4 t'O-b#!V 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 er 100,000 GPD:Copy to DWR,CCPCUA
Co
1s ZN ov Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) w �`` Method of test: 4J r oZ I-r-k S 't2—
3
70% hth Date Site Visited: `�-'�'-23
13b.Disinfection type: Amount: 7 O Site Visited By: ;
Form GW-1
North Carolina Department of Eavhonmerel�Llity-Division of Water Resources Revised 6-6-2018
Price: