GW1--05587_Well Construction - GW1_20240913

WJGEL CONSTRUCTION RECORD(GW-1) For Internal Use Only: f-"` ' `1-1
1.Well Contractor Information:
•'eel Li••••- pia.WATheZONE.S : ..
FROM TO .•' DESCRIPTION
Well Contractorx e p g
• 3-)1 Y ft. �;3J=it o1 ��t/tor- /`vt/e;
NC Well Contractor Certification Number '
:15:OIITEIZ;:G-r WRING'(fcitai 7ti casPd'we113)AIZ7 2ER;(i£a••lfoali)6f
Yadkin Well Company, Inc. PROM To _DIAMETER -THIcERESS MATERIAL
ft. ft. In. .
Company Name
al:MINNIWCASING:OR:TUBING((R'e idia illir dlikil l61V -
2.Well Construction Permit#: FROM TO . DIAMETER MICENN'ss MATERIAL
List all applicable well construction permits(se.UIC,County,State,Variance,eta) 10 ii ft 62. ft• g-0 c m- cA I1/
3.Well Use(check well use): ft. ft. in
Water Supply Well: s"3.7:;t 3':.'. ,_ '.":'.'•.•..:.. ,•:: . l Z
FROM TO DIAMETER SLOT SIZE THICICI SS MATERIAL
['AgriculturalL viunicipal/Public ft. ft In.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
°Industrial/Commercial ❑Residential Water Supply(aluared) .•:18::GROUT;':;a.. `•.'•t,,:..` .-- D
❑Irrigation ❑Wells>100,000 GPI) FROM TO MATERIAL EMPLACEMENT METHOD do AMOUNT
Non-Water Supply Well: tl ft. 6 ft �1�� A �m oai p�r7�o l a frolo e
❑Monitoring ' . ❑Recovery ft. ft �r
Injection Well:
ft ft.
❑Aquifer Recharge ❑Groundwater Remediation
Ki.9.SAN157GR&V213PAtle.( pulilicdii1d)s.':i - - --
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology OSubsidence Control ft. ft.
❑Geothermal(Closed Loop) OTracer il..20MBICSINGIOG(attifeVnaditia`n'a1"s}seeti'if'neceaiary)`=;::i:•"'r_'::;:: ..:•`..i;;'•:T'_.
PROM TO DESCRIPTION(color,hardness,soll/re&type,grain sire,etc-)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
Date Well Started F-a"(way to ft' 3 fried/ter,;/ A 7 L�:14•e .
4.Date WelI(s)Completed: '- ;? V Well ID#444.30.I ft �6� �t
Phone#:72 22c-• 'Zco ft. t
sa.QWellLocation: Fv2j .6r (.,eir.�.I(t�✓' '" L/� ` /��+' "`d/
t2d MMI A (3 D ft. 6 igeft' flan/ (i?7
'. $ Facility/DvaerName ' Facility Mit(if applicable) ‘Pke ft• le)-1-ft /7e/ /p,Tf Ore Aet. 5
' / f
3.3 I lie 6- 1.29J.)- Chap&l /A L/ ft ft.
Physical Address,City,and Zip NC, al to ft ft ' r
O aY.' Q... 00
4-/ 2 o/o, m\:1.' :.:4'• -,y.'!'^. -.
County �
.. _ _ ,,.:':1.�:
' 1 .PazcelIdeati{cationNo.(PIN) 33
J E P " r�---,
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1 �� 24 /�
(if well field,one lat/long is sufficient) 22.Certification: i r.:4.5, v4.4... ............ `'
: 6.Is(are)the well(s): C ermanent or ❑Temporary S:..sr. eof lad Well Contractor Date s
t .
., By signing thisform,Thereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or I`1t.lo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
' If this is a repair,fill out blown well construction information and explain the nature of the of this record has beenprovided 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 I 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: ® ��'a (ft) Submit this GW-1 within 30 days of well completion per the followings
For multiple wells list all depths if different(erarnple.3@200'and 2(g100')
10.Static wafer level below top of casing: 512 a ? (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
limier level is above casing,use ') Information Processing Unit, MSC,Raleigh,NC 27699-1617
CIO
11.BorehoIe diameter: t9 (in,)Bit Off: b.3.4 7 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: .41'i®e#111
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) Vt. Method of test: .4:,— Permit Program,1611 MSC,Raleigh,NC 27699-1611
70% huh Date Site Visited:
13b.Disinfection type: Amount: .7a1 . oZ Site Visited By:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
Price: