GW1--04014_Well Construction - GW1_20230612

N E L CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor
Innformaation:
eL Y / C� S s i4-.WATERZONES'%:'...
Well Contractor Name FROM TO DESCMPTION ,may
s„ ft. ft d @L ' V
NC Well Contractor Certification Number i 1l a ft 74,2
1� ft AI r-aw� 3 j 6 i)m r•ve
:15OUlER'CASING for`miilti'c'rised"vveIIs OR' (ifi'"licablie;_',_
Yadkin Well Company, Inc. FROM To Dru�txrxu T>�tnavEss MATERIAL
Company Name ft. ft 16.`IliINER'CASING'OR;TITBING -e in• _
•,
Jd
2.Well Construction Permit#: FROM TO DIAMETER THIcKNFss MATERIAL
List all applicable well construction permits ri.e_UIC;County,State,Yariance,etc) ft ft in 1 1 ;,pc,
3.Well Use(check well use): Pa p r�-7 ` - ® / ft. ft in.
ldG V
Water Supply Well:
FROM TO DIAMETER I SLOT SIZE I THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) lfesidential Water Supply(single) ft ft in.
❑Industria]/Commercial ❑Residential Water Supply(shared)
'.18:-"-GROUT
❑Iui ation ❑Wells>100,000 GPD FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. d Vi 2 '
❑Monitoring ❑Recovery ft. ft. d
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediatien
❑A ulferStora eandRecov ❑Salmi farrier i-1-SAND/GRAVFdiPACK rf:'n'"'licable'f:=._LL':-
q g �Y tY FROM TO MATERIAL EMPLACEMENT METHOD
[:]Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(CIosed Loop) ❑Tracer 20iDRTtLI1VGI OG attach'tidditianaI-sheetrif neceu"` -" _`
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCREMON color,hardness,soillrock type,grain size,eta
Date Well Started S-J6-a?) t/ ft ac ft. I I
4.Date Well(s)Completed:,5^10"a3 Well ID# r ft 1 7S ft i-te
5a.Well Location- Phone 4:gL9-26C f[Z GZ 7�ft. �<` ft-
ft. ft.
Faciliity,// Namme I , Facili/ty�ID#(if applicable) ft E��ft -. Y 7
2T/� L•�CaJc'V'�V�-��'L �l/Id� �C..� ;���^�2�fJ�"\ ft, ft - --
Physical
Address,City,and Zip ft. ft JUN
ske-
_; 1vrr�t$i.la it ,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwellllfield one
eJ 1alat/lloingissufficient) 22.Certifieation
L r -
�G o J ) ks� N p�. / r�C/ / a W �®
6.Is(are)the well(s): UVermanent or ❑Temporary Signature of Certified Well Contractor Date
_ By signing This form,I hereby cerb,fy that the well(s)was(were)constructed in accordance with
7.Is this a repair'to an wisting well: ❑Yes or i 411 15A 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 ofthe ofthis record has been provided to the well owner.
repair under#21 remarks 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-1 is needed. Indicate TOTAL NUMBER 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:- 486�, (ft) Submit this GW-1 within 30 days ofwell completion per the following:
For multiple wells list all depths ifdifferent(example-3Q200'and 2Qa 100D
10.Static water level below top of casing: (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwater•level is above casing use"+" Information Processing Unit,1.617 MSC,Raleigh,NC 27699-1617 A
11.Borehole diameter: (in.)Blt Off: SOS�j 24b.For Injection Wells: Copy to DWR,Underground Injection Control(iUC)
I Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Mir Nicni l 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 fl�A'
FOR WATER SUPPLY WELLS ONLY: �@ 24d.For Water Wells producing over.1".000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) I Method of test: AV Permit Program,1611 MSC,Raleigh,NC 27699-1611 IsL
70% hth Date Site Visited:L/-1/-Z
13b.Disinfection type: Amount: 35 Oz Site Visited By: 0 06
Form GW-1 --'— ----—North-Car olina Department ofE_viroamental Quality-Division of Water Resources Revised 6-6-2018
Price:_ 6