GW1--06153_Well Construction - GW1_20241014

W,,L CONSTRUCTION RECORD (GW-11 For Internal Use Only: , CP
1.Well Contractor Information: I
a)
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(l) ,-.5. 4i.WA1:Ll14ANES'�:: S .si',.1' .•:Th-,;.; - i ...:,:•'':::: :''.-•i.�,' • . ea •
FROM , TO DESCRIPTION
We1lContractorN a .S
o®ft e/o' t / I s
57)-- ft ft
•
NC Well Contractor CertificationNomber `'OUTER:ri-INC:(fd"Friiiill''-'eesed'vielsl:OR'af1VFT (ifsp licatilef;:;1-1 ': .
Yadkin Well Company, Inc. FROM ft TO ft DIAMETER m THICKNESS MATERIAL (=
CompanyName ® KISS IMCASING:OIt:Ti ING'heutl e."rmal clffiida fi) .^'". :A t:,.....:,,
2.Well Construction Permit ft: 'J®5 %.4 PROM TO . _ DIAMETER ,THICR sS �MATTERRIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc) */ ft. / / t ,` n- 'r 7 L,
' 3.Well Use(check well use): ft ft in.
Water Supply Well: ell: r,..'_;:V:s 3':;;4�:i::L;ti.:,-.:..,:_. , �. u ... .
Pp y •PROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
[Agricultural ❑Municipal/Public 'ft, ft. in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft in. •
❑lndusfrial/Commercial ❑Residential Water Supply(shared) •: 1'; xx• — .
�B.,GROUTs ;pat :r `.`ii
❑Irrigation • ❑Wells>100,000 GPD FROM TO~ MATERIAL PEMPLACEM.BNTMETHOD&AMOUNT
Non-Water Supply-Well:i;`>-' c,..•,'''y ® ft. 4`ft. l34d`e6�s pie
41 re"'
Q Monitoring, '�. (.:,'fi. :•-• ''t `a'""�w❑Recovery 4/ ft. 'ft
� . ����®�f� P ���ref
Injection Well:
DAquifer RecharAC T 1 [ CO24 ❑GroundwaterRemediation ft -
ji19rSAND/ilEaVF7"rg,9;CI�ittlipplicaO'Ie))"..... .._ ;•"=;o.:=. .,"r; - .
❑Aquifer Storage and.Recov-ery. ,:, ;*OSa1inity Barrier PROM To MATERIAL RMPr ACEMXNTMETHOD • •
QAquifes Ts&t':;': __-..3 ❑Stormwater Drainage ft. • ft
❑Experimental Technology OSubsidence Control ft.. ft . .
DGeothermal(Closed Loop) ❑Tracer 2UDRlffiINGI:OG.(attar]iadditi`until'slireififriee`nsavyf.; ?<;:.':>s';•" :' 'ar'=.a:.
OGeothetmal(Heating/CoolingRet1lm) ❑Other(explainunder#21Remarks) PROM TO DESCRIPTION(coley,-hardness,solllrack type,grain size,etc.)
Date Well Started ,S-•7'i-, 40 t ft /.�� e L t7-�e'xe
4.Date Well(s)Completed: 9-b 4'Well ID#A46'36 6 433 ft. I br ft 62�€ PPPaq.,
Phone#:33 771'4f 7 165 ft. /7 rt *id 1 � :k din color) .
Sa Well Location
)ski bo$� ieneJa,,, �JCPeil�l ,/eveityn wit 9 ft ree= fkr' ,ipaec;sigP4-( `�
Facility/OwnerNeme Facility ID#(if applicable) ' e j f %�p5�ft S I kth 8oC •
F7 ,•. ft ft o
5u,1�An.1-- gcl it ti r NiC a303 `: G� /3g1 .' iJ tc�./ . rze
ft ft. e •
Physical Address,City,and Zip o
d aA h • :i 1, EN ate:: _:.,.�` v, r•r '•1: ', yas' Enn .`+
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County Parcel Identification No.(PIN) (' er^; to a +�,. '®;' 400
0
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: - '�9J'��-- 'co A 3®® G"
(if well field,one lat(long is sufficient) �jI c '11 B/ r �� 22.Certification:
®! ➢0 ��t f• N s�` 7 W Pi b' cif
6.Is(are)the well(s): liPermanent or ❑Temporary Sign a of Certified Well Contractor Date•
s
By signing this form,!hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or RINo 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,full out known 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
cone:motion,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: /y p (ft-) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q200:and 2Qa 100`) _ --- .
24a. For All Wells: Original form to Division of Water Resources (DWR),:•
10.Static water level below top of casing: Q U� (ft•) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
limier level is above casing,use"+"
�' c�,� 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Al.Borehole diameter: (m.)$It Off: Kg Program,1636 MSC,Raleigh,NC 27699-1636
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12.Well construction method: e 0/��n$J✓. A®i'W Y 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the if
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS AY: re- m.A ee • 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
yibfst {�t ®® Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) / Method of test: Ai.^ ✓'.r
o Date Site Visited: —7•-0—9.'e?�
13b.Disinfection type: 70�o hth Amount: 5'A OZ Site Visited By: "Lc.' .'iii •' •
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Form GW-1 6� ,n m North Carolina Department of Bnvirunmental__ ality-Division of Water Resources' Revised 6-6-2018
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