GW1--03919_Well Construction - GW1_20230612

-'WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
®3 -In U C14 ZONES
FROM TO DESCRIPTION
Well Contractor Name
'L7r- 2'79f'-
-7 ft. ft.
NC Well Contractor CertificationNumber -15.1'.Ou rqTMM G',16� kJM 01-
Yadkin Well Company, Inc. FROM 0 1AMEM THICENESS MATERIAL
ft, in.
Company Name ;
ING1et,f&MNMCASINGI
2.Well Construction Permit iv: FROM TO THICMIMS MAT
ft. 6 Wn. 5 6A
List all applicable well constriction permits ri.e.0C,County,State,Parlance,etc.) 4 1 f" 5
3.Well Use(check well use): ft. ft in.TOB
E!td
�,�9(SCREE W�r--I —-----
Water Supply Well: FROM TO DIAMETER SLOT SIZE I THICKNFSS MATERIAL,
ElAgriCultural DMunicipal/Public ft ft. in.
DGeothemal(Heating/Cooling Supply) []Residential Water Supply(single) ft. ft. in.
111ndustdaI/Commercial EIResidential Water Supply(sharjed) ;jj G 0UT�: :r�- —
[]Irrigation OWells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD AMOUNT_
Non-Water Supply Well; 6 ft. L/ ft w-dk pa y
DMonitoring CRecovery el f, ft.
Injection Well: ft. ft.
OAquifer Recharge .0 Groundwater Remediation
FA (Xii$1i6ble)
DAquifer Storage and Recovery OSalinity Barrier FROM I TO MATERIAL I EMPLACMM=METHOD
0Aquifer Test ElStoirnwaterDrainage ft. ft.
DExpeximental Technology 0 Subsidence Control ft. ft.
DGeothermal(Closed Loop) OTracer
[]Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) FROM I TO DESCRIPTION(color,hardness,saWrock type,grain size,ate.)
0 ft. qrt 54601
Date Well Started 5-14-a3 T7 4-1g,ft. :�3577t. pr1e4l .
4.Date Well(s)Completed: Well ID# t�tkT^,.q.,—p
Phone#-910
Sa.Well Location: (fl 23-V`- 4,?3't Xnel A*Ad tfrA Ae;-m­�4o -5
Park C?� ft. ft.,k 1 11 ­ - --'. .;=-
Facilityffivnler Name Facility lD#(ifapplicable) ft. ft. "V t U
ft. ft,
Fut-oit Rive, L., 3164p At t
Physical Address,City,and Zip ft. ft 1 2
Ke-C
County Parcel Identification No.(FIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if ell field,one lat/long is sufficient) 22.Certification:
6.Is(are)the well(s): ELVCrmanent or OTemporary Signs C ell Contractor Date
By signing thisform,1heraby cerWfy that the well(s)was(were)constructed
0 nstructedin accordance with
7,Is this a repair 4
to an existing well: OYes or K�. 15A NCAC 020.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
b'this is a repair,fill out known well construction information and explain the nature ofthe of this record has been provided to the well owner.
rep
air under#21 remarks section or an 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 I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pagei if necessary.
drilled:—![- 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: '�65?3 e following:
For multiple wells list all depths if different(example-3 @2 00'an d 2 @ 10 0—D (ft*) Submit this GW-1 within 30 days of well completion per the
1 wale,level is above casing,use"+"0.Static water level below top of casing: 96 24a. For All Wells: Original form to Division of Water Resources (D)?VR),
If Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: Ik (in.)Bit Off: 10•0 24b.For Injection Wells: Copy to DWP,Underground Injection Control(111C)
Program,1636 MSC,Raleigh,NC 27699-1636 CP
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:CopYto the
(Le.auger,rotary,cable,direct push,etc.) county environmental health departine nt of the county where installed *
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing Over 100 000 GPL Copy to DV5,CCPCUA <
13a.Yield(gpm.) 0-0 Method of test: NC 276 -161 3:
Permit Program 161IMSC,Raleigh, 59 1
.
13b.Disinfection type: 70% hth oz Date Site Visited:-��%)A —
Amount: Site Visited By: 00
North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
Price: