GW1--05554_Well Construction - GW1_20240913

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
r at,, `Mut\. . fig.A .izoNLs ..,J...1.—1,�;:<,,-•i:�:=.T;«: -z: :...r pi.;,:- . ,
Well Contractor 1-•l9ame FROM TTOO : DESCRIPTION
ft. �--NC Well Contractor Certification Number g25FOUTER;CASING ffirmultt=ca"sed vellS.ORL1NFd2'ifa livable"• :' ' —I—
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERrnr. cU
ft. ft. r in.
Company Name !.
CT g 3 3.65INN ICCASING:OH`TQBING'(g edtheimatclosed=IiiiiP=:af't;"i:�_= ;•',' _..,.
2.Well Construction Permit#: �v�eg FROM TO DIAMETER THICKNESS MATERIAL CP
List all applicable well construction permits(Le.UIC,Comity,State,Variance,etc.) +)ft. 11 i ft. /�,o -in. p 7►p.=i PVC,
q C7
3.Well Use(check well use): [ft. ft ( in. ,v 1 = i
s.-
Water Supply Well: t17 SCItEEi�.G """_:".r:�.�.��1 • -,,: �-s.;^—.-,�-.---;nh�:c':+:�.'� E.
PROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Pubhc ft. ft in.
❑Geothermal(Heating/Cooling Supply) `air esidential Water Supply(single) • ft ft. in:
❑Industrial/Commercial ❑Residential Water Supply(shared)
g 18 GRODIV' 'w? ------1.--- ,-7 7,a -.""=-it 3
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT r
Non-Water Supply Well: . 'ft ,ps
❑Monitoring ❑Recovery Oft.
S' ft. � -n1, pave,/Injection Well: �� Pr.-,,S1 Witt pi)iv.ref
ft. ft
❑Aquifer Recharge 0 Groundwater Remediation
1519:.SAND/GRAVELPACEV(if rpplic"alile)=S' :1�'..�..`'t .-"•"_ r, .11.--....2.
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology OSubsidence Control ft. ft
OGeothennal(Closed Loop) ❑Tracer C20:DRI7 NG-11.:OG`(ittachsdditibaatilieee`tsifnecessn`ry); !:_ , _ �
,''
FROM TO DESCRIPTION(color,hardness,soillrock type,grain sizeete.)-
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
Date Well Started 7_. II-?oy 0 ft Tr ft 04`
4.Date Well(s)Completed:7,/b"a-6);/ Well m# . li'3 qv ft. 3t d ft 1 41 f So , /�vi-Li , .
Sa.Well Location: Phone#: �j/j �_��ft SjO ftielleirjilei
PM ft. 9 z ft.
Facility/Owner Nam �` Facility ID#(if applicable) ft• ft,
ft. ft t `.�y.'" }
Physical Address,� /City,and Zip gQo�•
ft ft i ('[D
..1 at/r / 21 RF.M:ARKCI-Q--:',,.. aY'u.::''Y'S--:""z-R ,77-t�.�/L,1'a71":44,024a,Yf",.2:'- �,
a .
County Parcel Identification No.(PIN) s_:;:err:.' A ...;,7 .,- 7.::"-.. --
t' x. L1
Sb.Latitude and Iongitnde in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: ;
6.Is(are)the well(s): ermanent or ❑Temporary S' a of d ell Con trot 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 peln 1.5.4 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 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. j,
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: i)
• 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 90)3- (ft.)
For multiple wells list all depths if different(example-3Q200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
'r?rt l
10.Static water level below top of casing: 7® ft 24a. For All Wells: Original form to Division,of Water Resources''(DWR),
If water level is above casing,use"+" kit") Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: CP (in.)B it Off• 5, 9 to 0 24b.For Injection Wells:Copy to'DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12 Wellfconstruction method: 6 �.
(ie auger rotary,cable,direct push,etc.) �� 0 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
county environmental health departs:t ent of the county where installed
,` FOR WATER SUPPLY WELLS ONLY: f
® wet) 24d.For Water Wells producing over 100,000 GPD: Copy to DWR;CCPCUA
13a:Yield, m IJ �a 4 ? 'Permit Program,1611 MSC,Raleigh,NC 27699-1611
.(gp ) ,z'/ Method of test: a g
70% hth -. , ;Date Site Visited: i 1` Y , . VV
13b:Disinfection type: Amount: 3'1®, OZ Site Visited By: I I '�.
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Fours GW-1 �® • A North Carolina Department of Environme-------Lntal Quality-Division of Water Resources,, Revised 6 6-2018 5
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