GW1--04412_Well Construction - GW1_20230710

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: •
I
1.Well ontractor Information: -
4 i 4-At-ty 6 t^ 0 -141 WATER'ZONES* ... . .. .. • _ -
FROM TO DESCRIPTION
Well Contractor Name I q i ft. IS-0 ft. 1 0/7�? ry
3® 3 6 A- 5--ft. 2x,ft. - - 10 rP 1 #��
NC Well Contractor Certification Number '-11 OUTER CASING.(for'midti-rltSed'wells)'OR'LINER'(if ap linable) _
Yadkin Well Company, Inc. FROM TO / DIAMETER THICKNESS,. MATERIAL
ft. / ft. ! in. /
Company Name i-,-� w a ' ✓✓ r • -
�,i�,,(y $ 1♦��—? J _16:WNER.-CASING OR,TUBING'(geothermal c osed-loop)' �:.•. -_ .. ._ /JA
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL -Kipt.
List all applicable well construction permits(i.e.UIC Cou' IStatt, Y ian @.) ..kili ft. G 3 ft. ®ri`/$in. & g Lib /i__/ ,J ett Sy
3.Well Use(check well use): ft. ft. in. L S w6�1,
tilt..._.ol.C^ Pr.,.,,�Y;.� . ... i 17.SCREEN • :-
Water Supply Well: rt,W03'5.L4. FROM O DIAMETER SLOT SIZE TIICKNESS MATERIAL
❑Agricultural unicip'al/Public f ft.,. i , E tQ
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. in. / V ` '—
❑Industrial/Commercial ❑Residential Water Supply(shared) tt • = --
❑Irrigation ❑Wells>100,000 GPD _FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 It. 63 ft. 4/.2.,-/+- / Aimpa
DMonitoring ❑Recovery ft. ft. �/31¢.tt —'
Injection Well: C
ft. ft. (3
, DAquifer Recharge ❑Groundwater Remediation
'19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery DSalinity Barrier FROM •TO MATERIAL. EMPLACEMENT METHOD t
OAquifer Test ❑Stormwater Drainage
❑Ex erimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer • 120:DRILLING LOG(attach additional sheets if necessary), '
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,Canines,soil/rock type;gram size,etc). r
Date Well Started S�Ja/`2 3 ,/ D ft. •C 0 fL . S®a I ,- <
4.Date Well(s)Completed: �19—�� Well ID#AAP C 3? 6® ft. 700
00 ft g,,. d
°
Sa.Well Location: Phone#: I3- tit"- /3% 700 n. �L0�ft 1'614ppdtJ � R 6ratry�
Mt( a@\ Luke a lei*Fat R41ra Eaev Y�p. . ft. ft. so IAA- Q
•
Facility/Owner Name 1 Facility ID#(if applicable) ft.ft. ft
S 44 p"1Ml ��V r` P�. gel v1✓L,e v Nt ft. ft.
rA
Physical Address,City,and Zip rm e. A Trip®lvi ft. ft • •- -
Ali CY 21'REMARKS'...___.
County f.
Parcel Identification No.(PIN)
) De - . ) Oil 114e( -71le . ,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: #I_ DI-. ) t�
(if well field,one lat./long is sufficient) 22.Certification: SOR of hoops ( )
�,� 3` 0 67666 p - N 5^19 -.? E
6.Is(are)the well(s): Kermanent or OTemporary
ignature of Certified Well Contractor , Date f a
. By signing this form,I hereby certfy that'the tvell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or , 'To -. I5A NCAC 02C.0100 or 15A 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 wider#21 remarks section or on the back of this form. P'
23.Site diagram or additional well details: -5
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 C
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary. -i
drilled: ® \ ry0� 24.SUBMITTALINSTRUCTIONS
9.Total well depth below land surface: 0 1 ®�6 (ft)
For multiple wells list all depths ifd Brent(example-3 t@200' »d 2(41100') Submit this GW-1 within 30 days of well completion per the following: p
,s/2.Z(�$ 24a. For All Wells: Original form to Division of Water Resources (DWR), Z
10.Static water level below top of casing: 3a �I 6Iflt 7 .) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" %` "
11.Borehole diameter: Irk I`�J (in.) I N 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 1 /
�� °� 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 lcy
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA e
Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
13a.Yield(gpm) Method of test: 9 4 �r (Kr
F�SI 4 P
136.Disinfection type: 70 o t Amount: OZ
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018 _
Price: S.e..9_, ,sir 4 04... -