GW1--05524_Well Construction - GW1_20240913

W1t1,1,CONSTRUCTION RECORD (GW=1) ";.;; For Internal Use Only:
1.Well
loContractor Inf fomatio
8 ddr'" t1,5 • ...:: •:„..•
u.1f1..WATE$`ZONEs�•.-A",>i;x..'s ..-it,i. •'. . �..• .. r�;, .. .
Well Co 'Name FROM TO DESCRIPTION
ft ft
•
NC Well Contractor Certification Number • _
T.13`'0175:ER LSING'(for liiiilfi:eggia ielTss:OR'I;METI.ITTi"Beall er.'i.'
Yadkin Well Company, Inc. FROM TO ,DIAMETER micamess MATERIAL P.,:.,
ft. ft.
Company Name
pp r1 SlisIVJ.+'R:GNSING` ItUDBING_atittiermireluseii3iiiiii ..- ?.i2.i ;-..
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2.Well Construction Permit#: `:.✓ a 0 2 g sr s a(2 4' FROM TO . DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIG Cowity,State,Variance,etc.) Jr t ft Li 43 ft L `i in. $D A-. I 'Ric.'Ric.3.Well Use(check well use): ft ft in. rah
Water Supply Well: :a.0.F2i 1Vrr..,6 u-. _.;: .;. :':`, : * :1: i :._ ::{^7._.�;
FROM TO: DIAMETER 1•SLOT VTR THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft, ft in. �` "'
❑Geothermal(Heating/Cooling Supply) ®'Residential Water Supply(single)
ft. ft in.
❑Industriai/Commercial ❑Residential Water Supply(shared)
p,1✓i alfatT'. ^.•':_, .,.i :LiP CfG:. ailY::_._.. ,. e:,31:7— :'.t�.`Ty1__,._ =' •
.,.. :,7,...
❑Irrigation ❑Wells>100,000 GPD FROM TO EMPLACEmxtrr METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 2 t. Ben chiT,5 rvNa•4y S
OMonitoring ❑Recovery ft. ft 9
Injection Well:
- ft ft
❑Aquifer Recharge .0 Groundwater Remediation _
1/4
❑Aquifer Storage and Recovery ❑Salinity Barrier i:PROM
SAN17/GRTYEI^Y,A.M.('f AERIAL);'•-.,.� .;;',�-^-•+:'o „
TO MATERIAL `EMPLACK ENTMETHOD (( A
❑Aquifer Test ❑Stormwater Drainage ft. ft �'
❑Experimental Technology ❑Subsidence Control ft. ft• -.- -..,_ ;;
❑Geothermal(Closed Loop) OTracer iiIO OBIIXJNGI.OG(attach'addtti'u"nals eett'if:nneeaosaiy ;
n Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,solltrncc type,min size etc.)
❑Geothermal(Heating/Cpoli
Date Well Started 8 P aa�� -is)
rLi
ft o B d ..
4.Date Well(s)Completed: a1 ^) We11ID#AAG- (�lL- ,,, ,,tit ft '+1,4 ft B/li i t r�I f
5a We11Location: Phone#: 3(-3ci - 32 ft. J4� ft -
Teciw1(f. ft, ft. ,
C u ITr rF"Qua /i e5 4 lag E' ."."1
Facility/OwnerName Facility ID#(if applicable) ft. ft ' ‘+�.'t,P`.. 1 .
. 2 L b 3 GWWa(t •k- Cvc�ili i au) It l�. limed�nvv ft. ft_ SEP 1 ;• 2c2_� ,,
Physical Address;City,and Zip 077055
ft ft `I ..
,J
County Parcel Identification No.(PIN) ..
.- 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: •
(if well field,one lat/lonng is sufficient) 22.Certification:
3(, (Z tT'/aIn NO, s-s-Go'° W ,/ . - - , 7-17 Li
6.Is(are)the well(s): C ermanent or OTemporary
�lgpature of Certifie. ��ell Contractor Date
By signingthisfonn,I hereby certify that the well(s)was(were)constructed in accordance with
' 7.Is,this a repair to an existing well: ❑Yes or 121.lee
15A NCAC 02C.0100 or ISA 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.
repair under#21 remarks section or on the back ofthis 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 coustmctioninfo •
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: 11 tC completion of well days p Submit this GW-1 within 30 da s comper the followingi multiple wells list all depths Vdi different(example-3Q200'and 2®100)
1
10.Static water level below top of casing: -lb (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR), ,
If water level is above casing,use '+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
' 11.Borehole diameter: ‘ Om)Bit Off: to d Oil. 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC) 4
r Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: , l fr l 4
24c.For Water SuppIq and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department f the county where installed C
FOR WATER SUPPLY WELLS ONLY: • - 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 110 Method of test: I + Permit Program,1611 MSC,Raleigh,NC 27699-16 1
70% hth Date Site Visited: fib'-L -2- I ��` �� v
13b• .Disinfection type: Amount: I oz Site Visited By: COO 0 ! '! �. �� ��'�
' - Form GW:4. . North Carolina Depaitinent ofunvironmental Quality-Division of-Water Resources • , ''Revised'6-6-2018 .
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