GW1--06242_Well Construction - GW1_20230925

'ii LL CONSTRUCTION RECORD (GW-1' For Internal Use Only: ,
1.Well Contractor Information:ra'ajeI.r°4,vviv-t. /�I ill)• 5.1.4:WATER:ZONES .....'Axi,. ',:ST ...=:t tlk: .. ,.: ZI.: _.`�
1.,. 1-C.:;_.... :. ,pit:
Well Contractor Nam FROM TO+9 DESCRIPTION
ft. ft
NC Well Contractor Certification Number
;15.,
,OOTEitCASING(fo"r'mu7ti=eest?d:`vells)0R12:NER Kill licable)±v-?;c;^t;.r ....,v
Yadkin Well Company, Inc. FROM - TO DL9IETER «.I S TERIAL
•f-I ft. Ng ft. 6•I P-, in. S P r 4'I Vile- P
CompanyName 3 (s`�(- r�� 2,16lININER.CASING:O1 iWlING:(geutfieermmalclosed=loop) .w`7"2=`. .:"'' 0
i.,ilhe3 //ct� G�r� _ ....
2.Well Constriction Permit#: l ) 1 2 S-W FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.Ulf County,State,Variance,etc.) ft ft in.
3.Well Use(check well use): ft ft in.
7a:SCALED ."` 7.7f--- 7.:.y:J__`,"7"_---'----------:_ =_.`__ -_ __.__..:=:;
co
Water Supply Well: FROM TO DIAMETER; SLOT SIZE THICKNESS MATERIAL
❑Agricultural Municipal/Public - ft ft in. 9.
❑Geothermal(Heating/Cooling Supply) I_`l sidential Water Supply(single) ft ft in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) ;le GROUTS °.v c - --- ^ ... `� -- `
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIA/Le. ``C9EMFNTMETHODSrAMO Nr'
Non-Water Supply Well:,._-A w,�' ��,,,.�,,,.� o ft. 2 2. ft. fi` Yli k` J!s f/C) l In p(•.:.`
OMonitoring t I. ( �I k,�?EteogVe3'y ft ft.
Injection Well: (fin ft. ft
❑Aquifer Recharge S E P 2 5 2 ( roundwater Remediation ___ _
i'.;19 SA1DD/GRAVES;PACK:(if npplica ile)7::` .e _ _"'_ k, :__. .
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO , MATERIAL SNIPLACEMENTMETHOD %
❑Aquifer Test Into;:i"* !'D Prr-cur�" Witer Drainage ft. ft
�„ 30-(3- t�rmwa
❑Experimental Technology ❑Subsidence Control ft, ft
0 Geothermal(Closed Loop) OTracer C20tDR.11111,1G1;OG:(attach`.addittanaI,sheetiifnecessary)
FROM TO DESCRIPTION(color,hardness,sell/rock type,grain size,etc.)
❑Geothermal(Heating/Co ' g Re ) DOther(explain under#21 Remarks) I I
Date Well Started 30* :o /'7���3 -••�p�q 0 ft i go ft j6®t( II-. 1---erti✓'S ®� ��g
4.Date Well(s)Completed: i t44091, ell UM V a 1 1 1-- i/D ft 13 0 ft g`p as" �,
5a.Well Loca og:
Phone#:33C�- 4f,S2-/3 I.q 110 ft. i tit(ft. g v 4.;,,'`/t., CTve y - fj,'-cc
G.(La m l c..�(TlaC h � p 4.6-'�)' 1 i 'I ft y a ft 6.�.tl,(/� G.,�y,r 1,��/'At_ l- •t-s
Facility/Owner Name 9'6 pa a,g Facility ID#(if applicable) ft. ft
"AU5*C1 , v U 1a''& S Gv:AK. pis ft. ft
Physical Address,C ,and Zip t�ti ft ft
W ; / 1 aeRENIARKsr y:.T :�.;:r':..- Y ._ _�-_�.�": ::::_ ..r
tC
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.Certifleatio,: •
.3G..®c. (faZ N SO 4II q ® w - iiie--2;......c__ 3/f1.-51.c5fi -2.3
6.Is(are)the weII(s): Bermanent or ❑Temporary si... Certified well Contractor Date
q .• ing this form,Thereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or fro A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy `4
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 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: Lid (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Qa 200•and 2@100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 15D ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use••+"
24b.For Injection-Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: / On.)Bit t D� Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 1 Y C. I 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
I (•-•''
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing'over 100,000 GPD: Copy to DWR,CCPCUA
t Permit Program,1611 MSC,Raleigh;NC 27699-1611
13a.Yield(gpm) Method of test:��/
n Date Site Visited:$ •/If-33
13b.Disinfection type: UN 2
7��o htll Amount: 1 y OZ Site Visited By: op:3 Ila
LA
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6.6-201 S
Price:. 1
CM