GW1--04410_Well Construction - GW1_20230710

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
MC/ilm 01011Il'S .,l WATER'7ANEsw:....1F:n:S:Ta. a1:..w� _ ._...1:;:. _._,,...,_.....
Well Contractor e FROM TO DESCRIPTION
ft ft
NC Well Contractor Certification Number c15:-OUTER CASING(for:multi-caieiiw`ellilORLINER(tfsppliealtli):_;'. s:r ?.
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS I MATERIAL
*--
ft. ft. in.
Company Name
y,I .Y6:`IsINER'.CASING'ORTUBING�(geotheriaalc`lwed3oup)e :'=7:2,M.�.','.::t.
2.Well Construction Permit#: 3•.y �j L• V -< V -3 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.WC,County,State,Variance,etc.) 4, %ft. 5.q ft. 6.or 3.-
+�in. j G
3.Well Use(check well.use): 1 ft ft in.
Water Supply Well: .17'SCREE1f. i. _ . _ ..�.� . .a = __-;._„,.....,,..L.....-,.. CA
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
❑Agricultural ❑Municipai/Public ft ft in.
ck
❑Geothermal(Heatmg/Cooling Supply) 1esidential Water Supply(single) ft ft, in. LA.
❑Industrial/Commercial ❑Residential Water Supply(shared) i18;GROUT: ____ __r x:e` .:___...__....`a.___" _ w-_.__
❑IsTigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: b ft 5-' ft &61-e.J.9a pco efto
❑Monitoring • ❑Recovery5- ft i ft1.$10o
Injection Well:
�� • j � ��°'�i�tt�
ft it
❑Aquifer Recharge ❑Groundwater Remediation 19YSAND/GRAVELPAIMC(tfapl calile)': -_:-:- __'•. ----- -' ""__-"-
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer i;.i2o DRIt 1N(1OG(attscliad3ltiiinn1ralieetaifiiiiials*)t_t`-:_`-21.:,.7=„:=^
❑Geothermal(Heating/Cooling Conlin Return) ❑Other FROM ' TO DESCRIPTION(color,hardness,saillreck type,grain size,etc.)
(H g/ g (explain under#21 Remarks) e
Date Well Started $3D-f 3 o ft. �q ft 5Q// Og-
4.Date Well(s)Completed: ‘'d-23 Well DV 44 I* / 7 Q'/• r�1ae'ft /ye '� f'�rA�„ 0fee 4
ldP Sa,WellLocatiou: (�Grrec.- 2
Phone#: aE... 3AV.- 'i ft. ft. �° L
4 -i J/e VC*.e' �'J4L f j&a v 41 Z y2*A a!„ter'. ft. ft.
• /OvmerName Fad' LD tfiapplipi,te r', C..r
a �_ t
19 0 1 �' G.i/ '(dl// C It/'f t. ® low 1 P� ft. ft I. Iv..."/. i ��� u., c)
Physical Address,City,and Zip i' `'1 ft ft III I 1 g 7023
0 2 3 its
•j� /e- • :•21 RF.NAlor4+"_ `..........r __....'!e.- ________:.__:_._-.2.______::_____,lIJ a'a
County T' !i`t Parcel Identification No.(PIN) in v.r�•:��� ?t �� ' f�l'x
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
CA
(dwell field,one 1at/long is sufficient) 22.Certification:
36 a.r. l o c1 N 21 rz,g, 3-gti V
• 6.Is(are)the well(s): Oermanent or ❑Temporary Signa,.,'of Certili :Well Contractor 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 pro ISA NCAC 02C.0I00 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 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 GW�1 is needed. Indicate TOTAL•NUMBER ofwells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
6
9.Total well depth below land surface: es20 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3(a)200'and 2Q1001
• `7 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 casing,use"+" •
11.Borehole diameter: (in.) 24b.For Injection Wells: Copy to DWR Underground Injection Control(IUC)
��jjJJ Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction meth d: tf )&t a t7 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct ush,etc.) Y county environmental health department of the county where installed
FOR WATER SU1'.PLY'WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA 2
(gpm) / Permit Program,1611 MSC,Raleigh,NC 27699-1611 4
13a.YieldMethod of test: a!d-
70% hth oz Date Site Visited: f L-3 0 -2 c(J , -
13b.Disinfection type: Amount: 5 •�a d Site Visited By: V /8
lrunental Form GW _ Quality-Division of Water Resources Revised 6-6-2018