GW1--04017_Well Construction - GW1_20230612

!'t'�f�,L CONST]IaIJCTIOI�T ktIECORD (GW-1) For Internal Use Only:
I.Well Contractor Information:
Well Con tractor Name FRO TO DISCRIpTtON
C/b .fit. W° rt / ®-zi v�
NC Well Contractor Certification Number ;15:OUTEIt'CASIlQG focmulti-as "eIli'ORT,INER tf,s""lii3flTa '_-
Yadkin Well Company, Inc. FROM zo nIAMETER THICIO�Ss MATERIAL ..
ft. ft in.
Company Name
�}y `.;1:&E0 ER:CASING:ORaMING; "eotlieimaldtised=ldti" '•- '
2.Well Construction Permit#: ��� i° �� FROM TO DIAMETER TMCTCWS MATERIAL.
List a7l applicable wrll construction permits(r.e WC,Cmmty,State,Yari mce,etc) 41 ft. 11 ft • ° • in. V a,�� o 7 1 vc-
3.WellUse(checkwelluse): f<' ft ® in. 8
Water Supply Well: ,S.C1iE��•:__ _; - -_ _. .. - - - - - --- - - -FROM TO DIAMETER I SLOT SIZE I TRICKNESS I MATERIAL
❑Agricultural ❑MunicipaUPublic ft It in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft in.
❑lndustrial/Commercial ❑Residential Water Supply(shared)
❑hri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: n ft �� _ 4 Ura
t
❑Monitoring ❑Recovery ft ft.
Injection Well: �'� ��r�
ft. it
❑Aquifer Recharge ❑Groundwater Remediation
1:19.SAND/GRAjrF,I'rPA.CIf'rf• ':li'c"able -- _ -
❑Aquifer Storage and Recovery ❑SallnityBarrier FROM To MATERIAL EMPLJ+CEMENTMETHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer '•2U:DRITMG-LOG''aftacl sddilional'slieefsir'necess '
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) FROM TO r ft DESCRIP•11ON color,hardness sail/rock e n etr-
"� ® ^
Date Well Started 5-aci_ ft. ��-
4.Date Well(s)Completed: >�m��'�� Well ID# AA N - 6 Z f, o ft
5a Well Location Phone#: °� - 3 2.- 1 21 ft ft
&4 Tr t7tiPi 6;rrJ1,,
Facility/Owner Name Facility ID#i(if applicable) 1 ft ft
3023
lad' JL I i'
ft ft .t
r
w�iLm- Pe.y.P®ill
Physical Address,City,and Zip iL ft � �� ar.`G ,a ura
Comrty s/�'r Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwellfield,one lat/long is sufficient) 22.Certification:
3to. 3(05-S-S'" N y�13�� W B
6,Is(are)the well(s): permanent or ❑Temporary Sig-61"Pe,
of Certifie&VeH Con for Date
.✓/
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MK. 15A NCIC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and Hutt a copy
If this is a repair,fill out]mown well construction information and explain the nature ofthe of this record has been provided to the well owner.
repair under 421 remarla section or on the back ofthis form.
23.Site diagram or additional well details:
8.For GeoprobelDPT 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 TOTALNUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages ifnecessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
a
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 00'and 2Q100)
° 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
If wafer level is above casing,use"+"/
11.Borehole diameter: , (in.)Bit Off. 4g7 0 ® 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: a 1:' P"a T1""r>N 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct pusb,etc.) J9 county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR CCPCUA
132.Yield(gpm) o Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611 <
70% hth / 0z Date Site Visited: I
13b.Disinfection type: Amount: Site Visited By:
Ll
Form GW_I_ - '`"" ' pronmental Quality-Division of Water Resources Revised 6-6-2018
Price: I
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