GW1--06049_Well Construction - GW1_20241011

WELL CONSTRUCTION RECORD(GW-I1 For Internal Use Only:
1.Well Contractor Information: 1 A‘1°
. �oQ�
Well Coahactor ame • FROM TO DESCRIP ON
� '�a�� 36.V'f. 370 ft S v I,° lift gu� &ktit
ft. • ft ;
NC Well Contractor Certification Number a ■—asa- 1
�I�OIITEI�;Ci1SING`(formulfi;ced:welLs7:0It'I�TER':Gfap"lic"ba'Ih);:`:=.�-
Yadkin Well Company, Inc. FROM TO rt .DIAMETER THICKNESS MATERIAL
ft.Company Name
16<IAi FLR:GASING.ORrWilING(aotlirrmal'doacdloo"'p�•.
2.Well Construction Permit#: FROM TO • DIAMETER _THICKNESS _ MATERIAL
List all applicable well construction permits(i.e. C,Comity,State,Variance,etc.) 4 I ft A J 5ft g.>-5 44L . /Y g -6(v
3.Well Use(check well use): ft ft in. r
Water Supply Well• FROM T.O _ DIAMETER SLOT SIZE THICKNESS MATERIAL
['Agricultural ❑Municipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) „18:rtsK01]Tr ,;,...1...:,_:::,..:!,...,; .... . - - -
❑Irrigation ❑Wells>100,000 GPD FROM To MATERIAL EMPLACEMENT METHOD 6.AMOUNT
Non-Water Supply Well: 0 ft. /evrft. efifteli+ 774m,i e7 p;;:te ktlgfsind
OMonitoring ❑Recovery ft ft
Injection Well: ft. ft.
❑Aquifer Recharge 17Groundwater Remediation
t`.'I9 BANK/GKAVFY A(?K(ifsPPl caliler . . . . •
❑Aquifer Storage and Recovery ❑SnlinityBarrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft
OExperimental Technology ❑Subsidence Control ft. ft
O Geothermal(Closed Loop) ❑Tracer 220DRIIIINGLOG(attach.iaditio"n'a1•sfiaetiif ieceissry•)';:':: .
Geothermal(Iieating/Cool Q,Retum) ❑Other(explain under#21 Remarks) 0M TO DESCRIPTION(color,badness,soil/rock type grain cue,eta)
['Geothermal
Well Started '/% ,Ate C) t. 71 ft 5p,'I
4.Date Well(s)Completed: 9.4‘94.441 Well ID#44�y_31-6 77 ft. / ft. AvE,6 ‘rea.7is
oc 5a.WellLation: Phone#: of— 7,26—RA'1ili oe ft. r�®>'ft ,, pJ y C`r'�,�`f/'C ie
ft. Y ft /
Facility/Owner Name Facility ID#(if applicable) ft l ;- -t _
it\r 'e.f 3.P-J jims Cr'ubm ik.Ir )4C ft ft p r T 1 /0>� _3
Physical Address,City,and Zip '..2 f6 17
As k e, :21:14.1RA A' ISM-;:.. .:r::..... .. i"
County Parcel Identification No.(PIN) — ..
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one g tat/long is sufficient) 22:Certification:
3 3-0143, N g ! e T5..70 W L
it
6.Is(are)the well(s): Permanent or OTemporary Si I e of C ed Well Contractor Date
By signing this form,'hereby cert i that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ['Yes or go 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 alibis 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 I�1 is needed. Indicate TOTALNUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 0 24.SUBMITTAL INSTRUCTIONS
tio
9.Total depth below land surface: (ft') Submit this GW-1 within 30 days of well completion per the followings
For multipllee wells list all depths if different(example-3(4200'and 2 a©100)
e 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 1 '' (ft•) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" �
11.Borehole diameter: 61 (in.)Biit Off: ,/�-.0 440,r` . 24b.For Injection Wells:Copy to DWR,Underground Injection Control'(RTC)Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:' it;•( ro 47..ry 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the 0,0
(Le.anger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER STIFFLY WELLS ONLY: • 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA 6'
tqr Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: (I
Date Site Visited: 1/z.t f Z ' *.
13b.Disinfection type: 70 o�° hth Amount: �6 4 OZ Site Visited By: in 6
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources - Revised 6-6-2018
Price: