GW1--05194_Well Construction - GW1_20230814

i- illg;(,L CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
.env 4S IC IV i 4:-WAl'1 (ZONES- ... , -- .. _:_ : .. . ' . . - • -
t FROhl TO DESCRIPTION
Well Contractor Name n Qe{t. .298 it. 12 ' /e ms
A45. A ft ft (Df
NC Well Contractor Certification Number :15:'OUTER CASING(ffeiliilti cised'fveIIs)'ORL INER(lap licaii e)' : . • 0
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft ft. in.
• Company Name
7:16i3111,0rR CASING:ORTIIBING;(atitlirsmarelosa:16•
2.Well Construction Permit#: 1 t 3 S q FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits z.e.UUC,County,State,Variance,etc.) 1 1 ft. /S�! ft 1/4 in* D i V
3.Well Use(check well use): '[ t it l 7 it in. �'
Water Supply FROM SCRFEI� .: _ ----- -. - • -- -- - - - -
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
:Agricultural ❑MunicipaliPublic ft. ft. in.
:Geothermal(Heating/Cooling Supply) -Wesidential Water Supply(single) ft ft in.
:Industrial/Commercial :Residential Water Supply(shared) • 16:'GROIIT. - -_ : - ---- - _--
:Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD de AMOUNT
Non-Water Supply Well: D ft. 31 ft. i,®le PIgi ?ooet) /6- 124,83
e
'
:Monitoring :Recovery ft ft ��7
Injection Well:
ft. ft.
:Aquifer Recharge .❑Groundwater Remediation
i.19.SAND/GRAvELiPACK(if'applicable),`_ -
DAquifer Storage and Recovery :Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD Ali�
:Aquifer Test ❑StorrnwaterDrainage ft. ft
:Experimental Technology :Subsidence Control ft. ft
:Geothermal(Closed Loop) OTracer .2l)DR1TMGY:eG:(attich addition`a7%beet'iifnecess"ary): -__ - __ _.. 1
:Geothermal(Heating/Cooling Return) :Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,solllrosk type grain size,etc.)
'Date Well Started g j 1(23 D ft SS ft. Soy' 1
4.Date WelI(s)Completed: $12103 Well ID#A'4/ —[,7 3 d S` - ft 340 ft G cau l
Sa Well Location: . Phone#: 77.-1,4 7^6li f ft ft
Jeteete5
fr. f 01l /3�P'e Ali ei_ &aa'113.13�� ft. ft,
S �: ..
[.... a � d �� is r_Facility/Owne
errNamee n Facility
/M#(if applicable) ft ft �/r r 2'1(1 ""'� n
�g, J a k !/e tt ' LS L tS tvyrb y �4 G4 ft. ft. n,U U 1 6• L V L J
Physical Address,City,and Zip J
0/A
L LA
County •t Parcel Identification No.(PRO
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: •
. a 79 Li Nl ., 3..'/S-2,- W g(' I o3
6.Is(are)the well(s): permanent or :Temporary Si ofC edwell Contractor Date
r 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: DYes or o 15ANCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out Mown well construction information d 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:
You may use the back of this page to provide additional well construction info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 G W-1 is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 124.SUBMITTAL INSTRUCTIONS •
9-Total well depth below land surface: ZO (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q200'and 2@100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10,Static water level below top of casing: 0 (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" //
11.Borehole diameter: LP (in.)Bit Off: (...03q 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 1/1 0 l et Nt 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
I �p� Permit Program,1611 MSC,Raleigh,NC 27 699-1 6 1 1
13a.Yield(gpm) Method of test: tvC It
70% hth Date Site Visited: 3—G7 3 61"4LE—•23 '
. 13b.Disinfection type: Amount: t OZ -Site Visited By: V g
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-20;
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Price:_