GW1--06001_Well Construction - GW1_20230920

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VVELL CONSTRUCTION RECORD (GW-1) • For Internal Use Only:
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1.Well Contractor Information:� -
�� i-® AS.+' 11,. i7z4 $-7A?,WATENES_ � ,sg
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' FROM TO DESCRIPTION = ... -
Well Contractor Node
� �� /%ft. $7 ft. 5-11 e,
06 t 'wee ft. .30111,101
NC Well Contractor Certification Number Sl5:"OTT1 :CASING(f6.rm.ilfi=c'a,dvtiells)'GRUNERfifs li€E6ie T.Ll_ ?;''.
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS 1 MATERIAL
ft. it. . in.
Company Name a^� qq /V�/ /�f�® Y6QASlNG;ORTIIBING:(geotlieimalela"sed3o"opt �:_' ^� . : 1
2.Well Construction Permit#: d ` G FROM TO DIAMETER THICKNESS MATERIAL r` �.
List all applicable well construction permits(I.e.UIC,County,State,Variance,etc.) 4 ft zr ft .1� €��3n. S D Jto�1 �� J
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3.Well Use(check well use): ft +A ft �n T
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Water Supply Well: FROM TO DIAMETER SLOT SIZE^�THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public - ft. ft in.
❑Geothermal(Heating/Cooling Supply) Pesidential Water Supply(single) ft ft in. '5
Dlndustrial/Commercial ❑Residential Water Supply(shared) 18 GROUTf a= ' :'_.1-_ �``:-'_-1,2v�-7--. = , —=--.= -- •
❑Inigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. Liu ft. 867.10.1x, u,, 9/
❑Monitoring DRecovery ft. 2.0 4it
Injection Well: ft ft.
❑Aquifer Recharge ,❑Groundwater Remediation = "
j 19:SAND/GRA1tELPACIC"Cifapplicable) -��7F:.-_r.`a: _.�:.:-."
❑Aquifer Storage and Recovery 0 Salinity Bather FROM TO MATERIAL EMPLACEMENT METHOD " -
❑Aquifer Test ❑Stomlwater Drainage ft. ft.
[Experimental Technology 0 Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer _':"2U:tiDR13lINGI:OG_'(atfieiffa`d3ilion`a7rslie'eti itfifFe s's'ery)::...77== -'---
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft °��°ft ��
Date Well Started 9.I -- nied 4.Date Well(s)Completed:61-1' 4 Well m# fl-7??., ft 94).dL J a �,p °r 4
5a.Well Location: Phone#:_ig; ge ft. ft
ft. ft.
L yi i-�
Facility/Own Name Facility ID# if a ft ft IYS rzr• i\i 11
'73Avike"s )-`4CMM S Qfrte- _ SEP 2023
Physical Address,City,and Zip ft ft yM
1 u2S RFM:dl21AR,�'a,.:'_'7!= .'...,"�c;..:.- a V : y:. -r'_ ::,7&15".
frAtli �ktY irtfo mm�fk.il Pr. °.>c4.•�'.j tirta u .
County Parcel Identification No.(PIN) DI :„y`:-0C
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ll++atllonggfir
�its sufficient) /� 22.Certification: j r�,�
Y t A. (,f% ( Net d T; rJig W /., P % at`P4
6.Is(are)the well(s): ii'ermanent or ❑Temporary Signa of C ell Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructedin accordance with
7.Is this a repair to an existing well: DYes or to 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information nil 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 51W 1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: ( 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: a (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3®200'and 2®I00)
° 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
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If water level is above casing,use"+"/
11.Borehole diameter: 6,� (in.)Bit Off: 4.®?II 24b.For Injection Wells:Copy to DWR,Underground Injection Control(lug)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: rb°p d 1/>V 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
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
s d Permit Program,1611 MSC,Raleigh,NC 27699-1611
m.
13a.Yield(gpm) f®� Method of test: ��
o Date Site Visited: b— ay e- tZ 4
70/o huh Amount: s,gie OZ Site Visited By: i
13b.Disinfection type: V l� ;
Form GW-1 -Nortli Carolina Departnieot ofFr viromnental Quality-Division of Water Resources Revised 6-6-2018
Price: I 0
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