GW1--03912_Well Construction - GW1_20230612

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+LIB CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
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1.Well Contractor Information:
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Well Contractor Name FROM TO - DESCRIPTION 51 ft.
JUN ?, ZQ23 ft
NC Well Contractor Certification Number ;15:'OUTER'CASING'(f6c'multi--cased-*eM'ORhI ER
Yadkin Well Company, Inc. x; �.�fir•-;= ;�a; tJn FROM I TO DL4METFR THICKNESS iMATERIAL s
�o, _ ft ft S in. d
Company Name V ,16ATWM CASING:OR.TIIEING `"ddtlit rival cl6 M
2.Well Construction Permit#:&JS Q% 1 2. •5-- �-U�3 FROM TO DIAMETER THICKNESS MATFI2IAL
List all applicable well construction permits(Ie UIC,County,State,Yariance,etc) ft. ft. in.
3.Well Use(check well use): ft. fL in
Water Supply Well:
PP y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL C
[]Agricultural ❑`M`unicipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) 13Residential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) r18i
01iri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: fr. ft. .4-.A (in
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❑Monitoring ❑Recovery ft ft.
Injection Well: ft. ft.
❑Aquifer Recbarge ❑Groundwater Remediation _
19=.SAND/Gl2AVE1PAC)S•ifa'"licable-.`..
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer :20rDRI1 SINGS OG attach`sadi$onzIslie`eis>f nacess—"` _
❑Geothermal(Heating/Coo Retnm) ❑Other(explain under#21 Remarks) FROM To t DESCRIPTION(color,hardness,sailltack a slze eta
Date Well Started ft. ;� fr. Sear (-I-t a
4.Date Well(s)Completed: Well ID# —C, t ft. S ft r�Eo vtt,� rQ�le 9/1 G
5a.Well
Location: ,3 ft i c,o, ft `� ��, ,t 42 A
0\ 7C.� l�l fd f7 ft. /& ft. 1 t r 11 it /(
Facility/ er�N®ame + Facility ID#(if applicable) ft. (70
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Physical Address,
City,and Zip ft ft
County Parcel Identification No.(PIN) /lets Z-v
5b.Latitude and Iongitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) Certifieatio
6.Is(are)the well(s): ftl ermanent or ❑Temporary ignab=of Certified Well Contractor Date
� � By signing thisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or Colo 15A NCAC 02C.0100 or•15.4 NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out/mown 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 ofthis 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 1 GW-l)is needed. Indicate TOTAL NUNIBER 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: (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdierent(example-3 a@200'and 2©100)
24a. For All Wells: Original form to Division of Water Resources (D)MR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1.617,MSC,Raleigh,NC 27699-1617
If water level is above casing,use
11.Borehole diameter C� Cn.)Blt Off: �/ � 24b.For Injection Wells: Copy to DWI,Underground Injection Control(IUC)
Prograrn,.1636 MSC,Raleigh,NC 27699-1636
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12.Well construction method: 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 tga
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FOR WATER SUPPLY WELLS ONLY: e4
24d.For Water Wells producing over 100,000 GPD: Copy to DWI,CCPCUA o
13a.Yield(gpm) Method of test: 1?+(o- Permit Program,1611 MSC,Raleigh,NC 27699-1611
70% hth Date Site Visited: 't-1 2-1
13b.Disinfection type: Amount: 30 Oz Site Visited By:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources evtsed 6-6-2018
Price: W ot �