GW1--05148_Well Construction - GW1_20230814

: I,CONSTRUCTION RECORD (GW-11 For Internal Use Only:
1.Well Contractor Information:® /�
Cr .L.W in ✓-(/' 0-'1_f f4d r J.4.WATEIZZONES Z:::_"..: i;; e:i;: •.
Well Contractor /� FROM TO 'DESCRIPTION - ___.
ft ft
NC Well Contractor Certification Number :15f OUTERVASINGOutamniti;eifedNiielleIGRI;INEROf liCitlile)'.' ".- '"
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL
J, ( ft. win' G r 0•>C m' I i D,f' 64ti.2.'r-C(-S%ee(
Company Name `.i16112sT. CASING:ORILBING;"eotliiimiirelo-sed=loo
FROM TO DIAMETER THICKNESS - MA ::;"_-
2,Well Construction Permit#: P��6+/d. a-y�3®®1� Sc r ^
List all applicable well construction permits(Le.UIC,County,State,Variance,etc) ft. ft. in.
3.Well Use(check welluse): ft ft in.
Water Supply Well: rf,V i^iiR`R�1.'z_�C =�:_'_ = �__'-: —. :::
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑IvI cipal/Public ft. ft. In. RI
❑Geothermal(Heating/Cooling Supply) f esidential Water Supply(single) ft ft in.
❑Industrial/Commerc .-. "a
g iah — 2 es�d h�Water Supply(shared) 7. ,
:E
❑lui ation µ'L �f�r p-�•$ klW ells'>100,000 GPD FROM TO MATERIAL EMPLA METHOD&AMOUNT U
Non-Water Supply Well: 1
PP Y (�,'� !]!1 ft 0 ft �t��i�`�t`�r� Ily i'ra/�• ire Rae-C
❑Monitoring • A U G 1 4 2`utRecovery 4�L ft. ft.
Injection Well: ft. ft a3
❑Aquifer Recharge I rr.n;p:':t- A,�,,, ..DGroundwater Remediation
DINQ't, Na I:19.5'AND%GRAV.EhP.ACK(ifappli613h1 :_- __------ •.___ ._.-- -:_'- --_._.- Z
DAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD ' li
❑Aquifer Test ❑Stormwater Drainage ft. ft 'it
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer rDRIJ;TS'NGTOG'(attacifil ditioriiirsliFitsif.necessary)a.:;_`- ..-
FROM TO DESCRIPTION(color,hardness,sail/rack type,grain size,etc.)
❑Geothermal(Heating/Cooks..Return DOther(explain under#21 Remarks)
Date Well Started_ _' ' • / /� Qj Q ft. C D it. S k�y S; I-4/5,'/, .1- 5,>�e
4.Date Well(s)Com leted:,_ C� Well ID# A P✓ 6 lD L/[ K_,,.,e P p s y � �r�Q ft. p� ft. r .),/l%ioGJe i�ye�,r(
Sa Well Location: (�,, �[ Phone#:S-6 S--257-2 o q g. ft I l q ft G k /c r / 7 j
.S c A z.a✓1 e S eirel 1'L( ft. ` f1 ft. i7C K Fo-►--e_y/ /475 —ei — Le
Faaciiity/O�wnerName / f Facility/i D#(if applicable) ft 3(e9 d�f ' F L.
SIX l LekivP( J , ( Aa.-cfra-A/ve_
ft. ft
Physical Address,City,and Zip ft ft.
SS � %zL RF.rir4zriz�.•. -`; -. .'w..,_,_. . "_..___.-...__:_L__ _-.> —�
C?Vo�
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees
(if Well field,one lat/long is sufficient) 22.Certific•ion:
05(14 190.13
„....-r-__h;Z.....-
6.Is(are)the well(s): rmanent or ❑Temporary =•f Certified Well Contractor Date
ti3e
:••signing this form,I hereby certify that the well(s)was(were)constructed in accordance with ',1
7.Is this a repair to an existing well: DYes or @IQo ISA 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 under#21 remarlr 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 TOTALNUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 024.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3G (ft.)
For multiple wells list all depths if different(example-3Q200'and 2Q100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water Ievel below top of casing: 6o (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing use"+" /If Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: a. (in.)Bit Off: t�•09 ? 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
A Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 14 i 1/' g0-14'-'f 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
FOR WATER SUPPLY'WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) dE� Method of test: A I t/ eg,__ Permit Program,1611 MSC,Raleigh,NC 27699-1611 . 62,1 I y o;t4
70% hth 'OZ Date Site Visited: ��'�'3 � �,�� /��,d�, 1-
13b.Disinfection type: Amount: � Site Visited By: 0. 0
Form GW-1 North Carolina Department of p nmental Quality-Division of Water Resources _ Revised 6-6-2018
Price:_
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