GW1--05533_Well Construction - GW1_20240913

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
®ckr' i
lJ I 41'WATE$7oNE5`':=. ; I I :cs?. ' r a
WellConlractorNam FROM To DESCRIPTION r
//7 t. /8'®`ft ( s 4, Q'
5 A ill it q$4,"ft b O
NC Well Contractor Certification Number M .�
]5"OUTEIZ'(a.F3SINGYfoimnlf4c'"a d"Sv OItT:ZIENER•':(if,"sp:lieableM:kw:Y:_ ...
Yadkin Weil Company, Inc. FROM TO DIAMETER. THICKNESS MATERIAL
ft. ft in.
Company Name 5r.
Q
1 `,gyp' V V T6S: . _Yr .• , ,. ..
2.Well Construction Permit#: FROM TO . DIAMETER; ?-i THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,eta) J ft.
hag ft _ G. m- e /rr Abe
3.Well Use(check well use): ft' ft "'
Water-Supply Well:
i37.'•SCIZ7 .:"-:.'.•::71:::;:'"rd7.1 �.r";`::��;-;>'.1-_- rs'-_R`...-., ,h.
PROM TO _ DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft in.
❑Geothermal(Heating/Cooling Supply) •, residential Water Supply(single) ft ft - in.
❑lndustrial/Commercial ❑Residential Water Supply
(shared) i0:Gii0U7C:>'r .ci':.. .. :171:> i.,r�...i;`°: .: -.i_ 7"i1.:'
❑Irrigation ❑Wells>100,000 GPD PROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT_
Non-Water Supply Well: 0 ft. e ft014--cAtar pp veep( .
:Monitoring ❑Recovery (,' ft' ils1)-e ft lan.siurr7 V Awed
Injection Well: ft. ft /�
❑Aquifer Recharge - ❑GroundwaterRemediation _
DAquifer Storage and Recovery ❑Salinity Barrierjr 86ND7 o' '`� a 'd'caliiej"'iiTs::",''""'' `;'= irik_ 'x:'•'- f,� ,'.
TROM MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft• ft
OExperimental Technology ❑Subsidence Control ft ft -
❑Geothermal(Closed Loop) ❑Tracer :20:D10); IGiOG.(zttac."dditi"oiiiThl eetaifiiieg sa'ry)r:'°:ni;'isi.= _-:`r;,-„ ni.
lim❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21Remarks) PROM TO DESCRD'TTON(cater,hardness,so0lrocktype grails size,etc.)
Date Well Started 7�? 9-02+/ //�� 0 U`d ft So 1 1
4.Date Well(s)Completed:7 f y Qum Well INa- a Oa /co ft ti6v ft r i .a f re r$4 h.Ye
5a Well Location: Phone#: /80.. A.s'-14798 ft. ft ,,I � �-
ft. ft
L4,fr Su 11i Veld P
Facility/OwnEName Facility ID#(if applicable) ft _ft.
U M n.j K�. PO)P 1 it S`�d®( �j Q ft. ft S ;:a L.-s-_,,; 7 i a p '..�,,•
•
Physical Address�,,("City,and Zip 9 . ft. ft. S p Y`f 4.e �.-
Ww i I.e, . !:2r5?iBly A'Rlfs c. '•1.e._..... .-,_:':i -c.,,Lt;',f. .i1c.`;j:triii Ze:.
1
County Parcel Idexit!ficationNo.(PIN) Irk:,,••,-,.i:r.. ..,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: L1§`''et'_ +:r?
(if well field,one lat/long is sufficient) 22.Certification: a
t4hf'?It6.Is(are)thewell(s)• ' S' ofC edermanent or ❑Temporary ell 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 ix. 154 NCAC 02C.0100 or 154 NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction inforhation and explain the native 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 TOTALNUMBER of wells (add See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled
24.SUBMITTAL INSTRUCTIONS 0 Ts
•
9.Total depth below land surface: Yan© • (ft.) Submit this GW-1 within 30 days of well completion per the followings '
For multipllee wells list all depths if different(example-30200'and 2Q100')
' 24a. For All Wells: Original form td Division of Water.Resonrces (DWR), .'I
10.Static water level below top of casing: /75" (ft.) Information Processing Unit,161710C,Raleigh,NC 27699-1617 W
If water level is above casing,use"+" • .
Il.BorehoIe diameter: 6 on)Bit Off. 4.0 5 S 24b.For Injection-Wells:Copy to,DWR,Underground Injection Control(IiIC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: G rr a r4 4-4 a 24c.For Water Supply and Open-Loop Geothermal Ream Wells:Copy to the
(Le.auger;rotary,cable,direct push,etc.) county environmental health departrnent of the county where installed
FOR WATER SUPPLY WELLS ONLY: - 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA `
hth ti I 13a.Yield(gpm) 41
Method of test: r! Permit Program,1611 MSC,Raleigh,NC 27699-1611 teN
U
70c/o Date Site Visited: .2/cs�.'l® y
13b.Disinfection type: Amount: 9 g OZ Site Visited By: 41 I
.'it ifts e0 , 3 0I®i-ZV
Form GW-I North Carolina Department of Enviromnental Quality-Division of Water Resources I Revised6-6-2018
Price:_