GW1--04015_Well Construction - GW1_20230612

WELL CONSTRUCTION RECORD (GW-1), For Internal Use Only:
1.Well Contractor Information:
-7
7
FROM TO DESCRIPTION
Well Contractor 11arne ' 1;1 ft GPM I/ Iva t n�
ft. ft. 0
NC Well Contractor Certification Number -,J15:0VJMR:CASING(f6i-afiIti sdd*v'dby:
2.
Yadkin Well Company, Inc. FROM I TO THICHIIESS MATERIAL
ft. ft. i I
in
Company Name .
OR TUBING(R06661i'
2.Well Construction Permit M. 3!Z4 FROM I TO I DIAMETER I THIM4gs ~MA
TERIAL
County,State,Variance,ea) ft t7 ft. I
List all applicable well consfructionpermits(L e.WC, ft ft.
3.Well Use(checkwell.use):
Witer Supply Well: FROM TO y DIAMETER -SLOT S= -THICKI�SS MATERIAL
ElAgricultural [IMunicipaLTublic ft ft. in. I
O&othexmal(Heating/Cooling Supply) *esidential Water Supply(single) ft ft in.
Oludustrial/Cnrnmercial DResidential Water Supply(shared)
111nigation E]WeHs>100,000 GPD 'FROM . I TO MATERM VULACEN=METHOD 1,AMOMT
ft
Non-Water Supply Well: 10 ft. 59TNTLIT &CIS
ElMonitoring ORecovery ft. ft.
Injection Well: ft. ft.
DAquifer Recharge C Groundwater Remediation
1 1-19-,gmw/imAVZV-FAMV(1f161i
CAquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL
CAquifer Test OStormwater Drainage ft. ft.
DExperimental Technology []Subsidence Control ft. ft.
El Geothermal(Closed Loop) []Tracer =20:DR GLOV.'(iitfiac %ia&t!6fi0-s]ii-etijf
I El Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) FROM TO DESCRUITION(color,hardums,soiVrock typ�grRfn
slu eta
Date Well Started E-UX-11 ft. ft. jl
4.Date Well(s)Compl-eted..,71-1." —
�, 3 Well.iD#AAR- —417 'J ft- ft SA-
5a.Well Location: Phone#: 7Vy- 2??-f 1X 11) ft. ft.
4 PdN
ft zilfttl
,ttj -on 191 '4,n. ft.
Facility/Owner Name Facility ID#(if applirabAl 41 tat, fL
ft. M 1�­
E R/F
i3
Physical Address,City,and Zip ft. ft. 2
county Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlang is sufficient) 22.Certification-
6 N Fri � Gl 3S77 W <1
6.Is(are)the well(s): Permanent or OTemporary Signature of Certified Welt Contractor Date -L
. X By signing this form,1hereby cer*that the well(s)was(were)constructed in accordance with �A
7.Is this a repair to an e-idsting well: OYes or 0 ISANC-4CO2C.0200or]SANCACO2C.0200 Well Construction Standards and that copy -D
T, (A
If this is a repair,fill out known well construction information and explain the nature of the ofthis record has been provided to the well owner.
re pair under#21 remark section or on the back ofthis form. 23.Site diagram or additional well details:
8.For GeoprobeIDPT 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 NUMBER of wells (add See Oven'in Remarks Box).You may also attach additional pages if necessary.
drilled:- 24.SUBN=AL INSTRUCTIONS
9
9.Total well depth below land surface: ,-,2 ft. Submit this GW-1 within 30 days of well completion per the following:
Gl
For multiple wells list all depths if different(example-3@200'and 2@100D
10.Static water level below top of casing: 9LO 24a, For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use Information Processing Unit,1,617 MSC,Raleigh,NC 27699-1617
24b.For Injection Wells: Copy to DWR,Underground Injection Control(lUC)
11.Borehole diameter: -10 -(4)Bit0ff: Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: r 24c.For Water Supply and Op Geothermal Return Wells:Copy to the
(le.auger,rotary,cable,direct push,etc.) county environmental health department the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
.-11?
13a.Yield(gpm) �5 Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
— y
70% hth Oz Date Site Visited: - .93
13b.Disinfection type: Amount: Site Visited By: &I
Form Department of Environmental Quality-Division of Water Resources Reviied 6-6-2018J
Price: