GW1--04380_Well Construction - GW1_20240723

iEL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:Vet
3G mS I + 5a.a:wAi zoNEs:FROM i TO DESCRIPTION ���Well on ctor Name )?( 231
3 / , S It iegi ✓tie- [ sipe
- Gfp A P 4 f I/ 13
NC Well Contractor Certification Number :1S?OII1�'CASING'(foi'mniti"rased.weli):OR (ifap'ticablef :,' i:
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name S16 tiNER.CASING:OR:1'u1 EiG'kelitliermai cloud=ltitip).
2.Well Construction Permit#: FROM TO DIAMETER TBICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State.Variance,eta) ft. ft in.
ft. ft. in.
3.Well Use(check well use):
I Well: t.j7RSCRE1`7,
Water Supply Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL ^
❑Agricultural ❑Municipal/Public ft. ' ft in.J A`.) I
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft in, P
❑lndustrial/Commercial ❑Residential Water Supply(shared) ;ifilVAOUT,':, 1 —
Oh-ligation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
❑Monitoring DRecovery ft. ft ----,
Injection Well: ft. ft. "'5
[Aquifer Recharge ❑Groundwater Remediation rt-
j.'19.SAND7GRA17-Ynli CK(Wil pliialile)i.':
DAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD '
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer '20:DRTf t.INGLOG(attach iidditidual's3eeta if'hides's'a y)a:'.'1 :_ '.'.. ..:. <' :::'
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heatin Cooling Return) ❑Other(explain under#21 Remarks) J'„�fr �1 r h vat,-�Qt'((J 1 t Ar
d
Date Well Started )9-2 tf �y —
4.Date Well(s)Completed:G./(,,-2it Well io#A�/.' !'d• J2ft. QQj ft g ,j O krL]
Phone#: ft. ft.
Sa.Well Location:
/ /�• ft. ft. • . .
ge/)ri Ail ye,.. t/ 1areI �rvvv(fire r /gPd (L,;
Facility/Owner Name Fac ty ID#(if ap cable) ft' ft.
ft ft !IJ[ '2 _ 2024
ft.
Physical Address,City,and Zip ft
/"LU lei" :.21F.MA'RTffi:' x �-+
•
County Parcel Identification No.(PIN) �.2' I- S,at " �� t"C 9 3 t
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:�( — � '. (
(if well field,one lat/long is sufficient) 22.Certification:
Signature of Certified Well Con ctor Date
6.Is(are)the well(s): ermanent or DTemporary
� 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: or 1,1Vo 15A NCAC 02C.0100 or 15A NCAC G2C.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.
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
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: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ‘.200 / (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3 z 00'and 2Q100)
10.Static water level below top of casing: I
00 24a. For All Wells: Original form to Division of Water Resources (DWR),
(ft) Information Processing Unit,161'7 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
(� 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.)Blt Off: Is 0Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: rak4`f 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: A 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 16 Method of test: .1r/
o Date Site Visited:
13b.Disinfection type: 70�O hth Amount: r OZ Site Visited By: 'r (
`-LvSe "fe►' 363 ' 4- rc4N�) i
Form GW-1 North Carolina Department epartment of Enviro ntal Quality-Division of Water Resources 41)(176, Revised 6-6-2018
Price: J