GW1--04389_Well Construction - GW1_20240723

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: 141)
1.Well Contractor Information:
m 1/s 144-` ' l?,14 WATEIi zoNES%_ : .Y:
FROM TO DESCRIPTION V
Well Contractor Name •tiClOt 4- /05 ft. D ft 7
4
._..
ft. ft
NC Well Contractor Certification Number RIG&M.,31* CASING(foi multi=rsse3 weILs7.O' R'LIh�ERryiariP'7icablNnt !"'
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
(1,
`✓ In p/ S.I.V FR:OASING OR:TUBING:Veothei niir lo�ed-188X'
2.Well Construction Permit#: I 1�J _�/ FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Comity,State,Variance,eta) 1 T L ft. / 3 ft in.
_f(�Ji.!f‘L
(
3.Well Use(check well use): ft. ft in.
Water Supply Well:
FROM TO D ER SLOTSIZE THr S TERIAL
CI Agricultural ❑Municipal/Public ft in.
❑Geothermal(Heating/Cooling Supply) , .esidential Water Supply(single)
ft ft. in.
❑Industrial/Commercial OResidential Water Supply(shared)
❑ltrigaffon ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 24 ft.
[Monitoring DRecovery ft. ft
Injection Well: ft. ft. —
❑Aquifer Recharge ❑Groundwater Remediation
I'B.SAND/GRAVEIiP,ACIC(iEipplica�il-O `::
❑Aquifer Storage and Recovery ❑SalinityBarrier FROM TO MATE L EMPLA METHOD -
❑Aquifer Test ❑Stormwater Drainage ft.
❑Experimental Technology ❑Subsidence Control tx,..",, ft
❑Geothermal(Closed Loop) ❑Tracer 20.DGLOG attach'i tianalsheth If necessary)"
❑Geothermal(Heating/Cooling Return) ❑Other FROM TO DESCRIPTION(ester,hardness,soillrock type,grain size,etc.)
(H g/ (explain under#21 Remarks)Date Well Started • •2 /� 412 ft' 400 ft. y � ��
4.Date Well(s)Completed:
a' if Well ID#Aria ,231 fooft ,„Flo ft- viol, . P)k
5a well Location: Phone#:�/y -\Clj i1 --[4't7 no ft. 4 7 Se ft O�I_� k,.Lj � Cr() #- heir.
1 ft. ft. j
.NOS;)N Curcu rk.4 ft ft. ,..�." .l t..:,
Facility/ Name Facility ID#(if applicele) 2
slft ft II It 211n 24
Physical Address,City,and Zip ft. ft. .}
4v`( tk-CS wa-s 4A3-- t,4.. 21 RtMARYCC. tt .r c 'TT
6.
County Parcel Identification No.(PIN) i3' .i• -re c•]`iI L v at
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: :71
(if well field,one lat/long is sufficient) 22.Certification:
3L . sty, 2Su N 1 , 1 $, .5`2q W064"-- C`J
6.Is(are)the well(s): jiQPermanent or ❑Temporary
�� •�
Signature ofCert ed Wet 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: [Wes or, Xl,No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information an`d 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 G IV 1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
dulled. 24.SUBMITTAL INSTRUCTIONS
4
9.Total well depth below land surface: 9 1 Y (ft)
For multiple wells list all depths ifdii different(example-3Q200'and 2Q100'j Submit this GW-1 within 30 days of well completion per the following:
(1 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 14 VV Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter:
/- 24b.For Injection Wells: Copy to DWR,Underground Injection Control(TUC) 'O
(in.)B jt Off: Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Lf'e 1 fti T A// 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 over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: ( j Permit Program,I611 MSC,Raleigh;NC 27699-1611
70% O OZ hth Date Site Visited: �— 27cg
13b.Disinfection type: Amount: Site Visited By: ^I 6
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
Price: