GW1--05561_Well Construction - GW1_20240913

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jv WELL CONSTRUCTION RECORD (GW-•1) For Internal Use Only:
1.Well Conhacto Information:
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Well ContraccttoorName //per }FF FROM TO .•'' DESCRIPTION
14 L ..,�'�yi 6 IL
1-1
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NC Well Contractor Certification Number ;;I5?Oe ray GAS6G;fn multicca's2HtiveII"Olt
Yadkin Well Company, Inc. ( ,j lrICKN ss MATERIAL
FROM TO DIAMETER TffiQaII+SS MATERIAL
ft. ft j'in.
Company Name
Li
(' g� `'j s 16STIlli ROASING:01Z:l u1kiIl!TOVeriitliermisi elo'se3=1aop7`• ;Si�v:: j�
2.Well Construction Permit#: 6 I A 4.J 8 C FROM TO . DIAMETER THICKNESS •v:MA U. `�_
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) +I ft. (01 ft ‘r �1 q� m. f n 4 j/ f_� ,C
3.Well Use(check well use):
fit l ft F in. ! V .et l�„
Water Supply Well: s:17 SCI EW,="i•:fri.h ,;',:;:_:;;-: :'-�T': :u'; ^f:;..s=� gar`: - ,-_'.y,. '.:.
FROM TO DIAMETER SLOT SIZE TIUCKNESs MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
Ch
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft in.
❑Indushial/Commercial Ktesidential Water Supply(shared) "ie:.diftiilI ''' •_ "•"i :2S;r . :: is :;"a i:ic :�< N'i ti :u.u "r"`t ....
❑liiigation ❑Wells>100,000 GPD FROM TO MATERIAL 'EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0
ft. ail15-ft (444 f d--t City) p reJ
❑Monitoring ❑Recovery ft. ft 1 , 60.9i
Injection Well: ft. ft J
❑Aquifer Recharge ❑Groundwater Remediation •
❑A uiferStora StorageOSalinityBarrier i 19.SAND%GR`P.EI�?cAtjk(if thiicab1ej i-T .:'::•->a= n,I.: , .
fl g RecoveryFROM TO MATERIAL :EMPLACEMENT METHOD :
❑Aquifer Test ❑Sturtnwater Drainage ft
❑Experimental Teclinolegy ❑Subsidence Control ft. ft.
❑Geothermal(Closed Took) ❑Tracer i20 DRIEt IGZOG'(itt elcaiddifianal sheets'if ne Butt y-)`; :on1-3., ;':: ?"'__?':,7:e .
. ❑Geothermal(Heating/Cooling .etum) ❑Other(explain under#2l.Remarks) FROM TO DESCRIPTION(color,hardness,solllr/oc�k type,grainsiia,etc.)
Date Well Started'7=,_ d1 /_� . - _ ft .� ® r ,- (�
4:Date Well(s)Completed: 5 -� -�' Well]D#,61,-t Q q'• --- ft 3 5— ft d, r
.. , Phone# fit. fit �i ��'� ✓° G✓!s
'•' •
~ '5a.Wef Location:, •' .i1 : :To'.403� ply. l� 5 �� itivve11 ��d q t :'
//�� / p B fit. r� ft / l
CJn.'.. Goo rsGl; Goocitl;;L'..J020 dPa�r./ S 0 M j eGl llt�tj 59�1/ �lv
Faeility/OwnerName'. Facility m#(if applicable). ft 456 ft .0 Grey oy�j�G m
.0 . S' 9 q q55 fL y&v ft. er
7
n-9 I Physical' fig;City,.1911amp .-a� (V/ / ���. ��Q�6 fL fit d ��� /ry/y� t o�
i�aa d! t.alEmm TCC f,,,. ....'::;. i:"`c!. z;::i::e i �t u../1 L�t cr•9_}" •'.. '
County f A ��.• PamelIdentificatioallo.(PIN) F�.`m"' "r g-�3 eJ.� Li' ..• i
'.., 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: S E P 1 $ 2021 "`'•'
gala field,one let/long isnnssufficient) �!j �y gel 22.Certification:
• '' .3 SV''22,6 N ad./ , O R'J W "7125w;) t If,S;I,cx �'.-y
D"�`i Vic`}; u �y..,e, ,g ,
.•• - 6.Is(are)the well(s):*ermanent or ❑Temporary Signature of Cettifi'd Well Contractor Date
> ` s - •By signing this form,I hereby tern;fy that the well(s),was(were)constructed in accordance with
•
'`;'7.Is this a repair to an existing well: ❑Yes or X1NO ISA 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 remark section or on the back of this form.
23.Site diagram or additional well detain: •
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—1is 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: _5)2.1 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifd(ferent(example-3Q200'and 2Qa 100) ,
10.Static water level below top of casing: I®��))l 24a. For All Wells: Original form'to Division of Water Resources (DWR);R);
V (fit.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing use"+"
11.Borehole diameter: 6 cm.)Bit Oft C t,.0?6I 24b.For Injection Wells:Copy to DWR,Underground Injection Control(I•
TC) '
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: t?/ee feV4/ 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: • i
E� Method of test: ei a t' 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA r
13a.Yield(gpm) 6 Permit Program,1611 MSC,Raleigh,NC 27699-1611
70% hth Date Site Visited: 1 s la I d2 y
. 13b.Disinfection type: Amount: - OZ Site Visited By: 1 I _
C .. •i�
Form GW-I North Carolina Department ofEnvironmentatQuality-DivisionofWaterResources ' Revised6-6-2018
'Price_