GW1--06156_Well Construction - GW1_20241014

4WIErL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well Contractor Information: s'; II
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ti.-, 'i � Uhl j4..WATEIt`ZONESi^>v3's '.r•.:..:7.'.:
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RROht TO DESCRIPTION
Wolff ContractoiName
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NC Well Con ctorC 'on Number 2:16:'OUTER;:CASING'(ffi'i•miniisFesed'Sv• eIIa7`,ORTx'I1V$lt,(ifs"licalile
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL _ ki .
.4. i ft. g, 0 ft. 6. 11 sat- �p9_-7 8 ,.p v .
Company Name Q fl '
1 0 ' - \ 16'aINNFRiCASING:OR'XQBING:(pealieimirelo's"ed citi •:-:::..:r:.....• .
2.Well Construction Permit#: w FROM TO DIAMETER THICKNESS MATERIAL `c
List all applicable well construction permits(i.e.UIC,Cowity,State,Variance,etc) ft. ft in. V P..V�/
ft. ft in. I
3.Well Use(check weIIuse): _ _ : . . =-----• -- - •.^_, -
z17::S. =: S.rr'•:is-. : ';a S, _ _ __
Water Supply Well: FROM TO ' DIAMETER SLOT Si7.' THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic ft. ft in
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft ft in.
t ❑lodustrial/Commercial ideatial Water Supply(shared) ,Itl`GAOUTC :'.%:.. :r:'.•:;;:': ......_ il.':1-.'_;: .:. -- -
1 ❑irrigation ❑Wells>100,000 GPD FROM TO &IATERIAI. v EMPILACEMyENTMETHODeeAMOUNT •
Non-Water Supply Well: ft. r ft �®6Z,°'p� 4. 1s @roof-
,.. .
❑Monitoring DRecovery ft. ft t
Injection Well: ft. ft
['Aquifer Recharge ❑Groundwater Remediation
i119.SAND//R4VEratiktIe(rPi p'613—I'ej - " '.- -..- .'. -'
- DAquifer Storage and Recovery ['Salinity Barrier _ FROM TO MATERIAL EMPLACEMENT METHOD
['Aquifer Test ❑Stonmvater Drainage ft. ft.
❑Fxpedmental Technology ['Subsidence Control ft. ft.
/ , ❑Geothermal(Closed Loop) ['Tracer r;d .!Mt:DRIPI:INGI:OG(attachadditinnal'sheetiif neccninry):•:,..-.' -••.-: :-
ti ❑Geothermal(Heating/•Z.olin turn�).� ❑Other.(explain under#21 Remark's) FROM TO DESCRIPTION(coIo;LardneA salUroek type,grain size,etc.) •
Date Well Started r - U ''- l . •' ' ,j).IL i ft 0 6 r
'f
I
4.Date Well(s)Completed: i;- 6 ''I.4 Well ID#/�� '• ‘ `j(ft 7 t' t •c,:• •- I' ?
° Sa WeIlLtication: Phone#: 402--cis-/C�� ' 1, ft. ` ft
1, A4-e",A—rrke.h. Croicci t C t' `li -r jl ft. i'`' ft • __ ..• _ _
c Facility/OwnerNameQ ' /� (• FacilittylID#(if applicable) . ft. i; (� ry r�
�iW R. , W , lid � ° ft ft if Lr+ ` '. LU�} —
0
Phy�sica�llAddress,City,and Zip it. ft - •
, . - .
6/t/ ( i fie.; •
:2I I2ETfA.vcs...... :..' ..-
County . Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: • P.
(if well field,one lat/long is sufficient) U. C
22.Certification: f r
3(p.3�J`J3C,JrQ N'�,,1��L. �0 w ^d it , .f ' %J' • - - .
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�i3. ice"" , j ' ,f `� �f.
6.Is(are)the well(s): i ermanent or ❑Temporary Signature of Cei ifiecl Tdil Contractor
Date
By signing this form,I hereby certif,that the well(s)was(were)constructed in accordance with
�' 7.Is this a repair to as existing well: ❑Yes or Va I5A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a copy '
U If this is a repair,fill out imawn well construction information end explain the native of the of this record has been provided to the well owner.
repair wider#21 remark section or on the back of this form I
23.Site diagram or additional well details:
8.For Geoprobe/APT 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 NUMEF it of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
8 ..114.SUBMTCT 4_;INSTRUCTIONS
! ..1
9.Total well depth below land surface:_ . �'. (ft) Submit this•rp\;'=1 within 30 days of well completion per the following:
For multiple wells list all depths 4fdifferent(erample•_.: %:'L'! an ..-;• !I,,1 •.
ei ,(� 24a. For•All Wells: Original form to Division of Water Resources (DWR);
10.Static water level below top of casing. �- .. . - (ft') Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 d
If water hvel is above easing,use"+"
11.Borehole diameter: 6 tin.)Bit Off: 24b.For Injection Wells:Copy to DWR,Underground Injection Control(UUC)
9.3
• , j Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: ii-,, a : `,l ":•-';.' / ' 1`'lI' 1 '�' 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(ie.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installer:
FOR WATER SUPPLY WELLS ONLY: • , • 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
(gp ) .I.C "p g, Permit Program,1611 MSC,Raleigh;'NC 27699-1611' („? (t1
• 1.3a.Yield m •,wear.'d of test: E h
70% hth ,� Date Site Visited:
13b.Disinfection type: Amount: OZ ' Site Visited By: 7.k`7 s-( •
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018 '
Price: 1 -,,_ ,,,,tr, _ S'.