GW1--04021_Well Construction - GW1_20230612

!f'�]LL CONSTRUCTION RECORD (QW-1) For Intelmal Use Only:
1.Well Contractor IIn/f�ormgation�:
W14:WAM-ZONESa
Well Contractor N e FROM TO DESCRIPTION
r ry 5.2". W-
u�` Y " e k% ft �7
NC Well Contractor Certification Number r9 C &�a
15::OUTER�CASING ftiiYmulttica3e • aM OR'L11vFR'CtEaIIcable:`_.:.__._.' {
Yadkin Well Company, Inc. FROM To DIAMETER THICIQd+.SS MATERIAL. - F
ft. ft in.
Company Name
_16:IIdNERCASIIQG:Olt.TIIBIlIG '•eotlidi�mal`ddiidloo
2.Well Construction Permit#: N FROM TO DIAMETER THIQINFSS MATERIAL
List all applicable well construction permits(Le.Ult"Comity,State,Variance,etr_) 4 ft 1 °i`13 ft e P Y S ' 0-2 e
3.Well Use(check well use): ft. ft in
Water Supply Well: 5'
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) V<eaidential Water Supply(single) ft ft in
❑Industrial/Commercial ❑Residential Water Supply(shared)
01crigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q
ft 3° ft. atine� pa J,ed
❑Monitoring ❑Recovery ft 45-°ft m 5pa u"l -e
Injection Well:
[:]Aquifer Recharge ❑Groundwater Remediation
1'19.SAND/GRAVEL PACK if •liciible
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO MATERIAL E&IPLACEMENrMETHOD
❑Aquifer Test ❑Stormwater Drainage ft ft
[]Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer 120i3)RTT,1_.IlVGZOG attacliadditiotiaTalieetiifneeess
❑Geothermal(Heating;4Cooling Retum) ❑Other(explain under 921 Remarks) FROM To DESCRIPTION(color,hardness salllrodc a size,eta
Date Well Started v m > e) ft. gg 0° ft Jo,L. ��W
4.Date Well(s)Completed: S' +� Well ID# � �P9 GlYr q� ft ���'ft P�i� QUAe
5a Well Location Phone#:;�.:�(c-91$ — 7 3 J 3 ft. ���J ft r"� p4 An
ft ft. l `"l,,,r --) •
F!!a��cilityy/�/Owner Name p y Facility ID#(if applicable) R' ft1 2 9--•1
lrtL,l® 3 ft ft
UQ
Physical Address,City,and Zip ft. ft
County /LVG•• Parcel Identification No,(PIN) at q0
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
6,Is(are)the well(s): permanent or ❑Temporary SlgagK of Cerffcd Well Contractor Date
�� By signing thisform,I hereby certify that the well(y)was(were)constructedin accordance with
7.Is this a repair to an existing well: ❑Yes or ISfSV o 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,f ll out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on 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 1 GW51 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: ® 24.SUBMTTTAL INSTRUCTIONS
m
9.Total well depth below land surfacer (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3Q200'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 water level is above caring,use"+"
, @ 24b.For Injection Wells: Copy to DWR Underground Injection C
(m ontrol(IUC)
11.Borehole diameter: .)Bit Off: program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copyto the
(i.e.auger,rotary,cable,direct push,etc.) 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
-Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: /�'
o Date Site Visited: �'3 m��
13b.Disinfection type: 70�O hth Amount: •2L OZ Site Visited By: ,D.
Form GW-1 North Carolina Department of EPvironmentaaQunlity-Division of Water Resources Revised 6-6-2018
Price: �_.. _ -------- — 1—` --