GW1--06251_Well Construction - GW1_20230925

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: '
o3176/1 aPrig/1a-`s (T. 4 WATE$2ZONES.?::._._:;`u`:_::?'wt;:... _�._-1.'. i. - , r
FROM TO 3DES
Well ContractorNanrt 334. 3 S."' -5 I NPA.4, -1 eke_ce
91 5'ZIA ft. ft i I
NC Well Contractor Certification Number •,
:i15.`.OUT7;R:CASING.(f6"r':iniiIti=eased;�v�s)OR'I,IlVER gip•licable)l�_�•�--:. ":
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL 1
ft. ft. In.
Company Name 16rINNEgCASIr1G:OR.TAKING:"(ge"ritlier`malclated=loop)'Q22:2 -"",,211`f I::'"i.
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL. 13
List all applicable well construction permits(i.e.UIC County,State,Variance,etc.) +" ft 3 ft in aLi-tee i Cr
3.Well Use(check well use): ft ft 1R
Water Supply Well: FROM TO , DIAMETER SLOT SIZE THICKNESS MATERIAL d
€gricultural ❑Municip'hllPublic ft. ft. in. )y
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❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) :38 GROUTS` :__,_."^_-°' . _._ __
❑Irrigation ❑Wells>100,000 GPD FROM , TO MATERIAL _ EMPLACEMENT METHOD&AMOUNT_
Non-Water Supply Well: e5 ft. Pit ft 8-v4.Q.A �OeWr'
:Monitoring ❑Recovery ft. ft Cl',
Injection Well: ft. ft 3
DAquifer Recharge ,❑GroundwaterRemediation _. _ _._ :_ ___ ._
i519.SAD%GRAVEii_PACK'(if spplicalile)L:.;: "-_.. :�::___...�_._.-k:;.:<a'.2-: :
DAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD '
DAquifer Test ❑StormwaterDrainage ft. ft m
❑Experimental Technology 0 Subsidence Control ft. ft 7)
❑Geothermal(Closed Loop) ❑Tracer ::201DR11S +IGT:OG:(Attarch's3ditio`naTsheeti if.ifecevary)',. ::: �=::::y' 3
FROM TO DESCRIPTION(color,hardness,soiVrock type,grain size,etc.)
❑Geothermal(Heating/Coolin Return) El Other(explain under#21 Remarks) sft. ' Y
Xs
Date Well Started �Q �y ® ft ��s Z.
4.Date Well(s)Completed:I ®--,013 Well ID AP"-7 P 2 S"3.ft 4f,`�.� � j ir
Sa.well Location: 3"."
e, 10 , ite
Phone#: �-yly-13}D • ft. ft
,•--, �.-.. .-. _ _
i; r ft, ft. i
Facility/OwneteName /Facility ID#(if applicable) ft ft
eSpnik- erman Nd. Task Sew ft it. Sr P 2 5 2023 I
r_ Physical Address,City,and Zip ft ft IrtfJC Ia4i r i:,r;.. „.4 -,4.3 Ian;;
1 CWW\1(1 ie,21iRRMARKR.f==". ...DD r:4_ .i}! .Z,_-�._:;`_:-. ,::t:-::.:i
County Parcel Identification No.(PIN) � . AMY T, g l d, e, _
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: `� 1.
L� rk -5-4p ,
(if well field,one lat/long is sufficient) 22.Certification: pQ
36' /. 6 S Y N Sr° nt d u g' W BB • '�
.dam •
6.Is(are)the well(s): ❑Permanent or OTemporary S' of ed ell Contractor , Date
By signing this form,I hereby car*that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or L9No ISANCAC 02C.0100 or ISANCAC 02C.0200 Well Construction Standards and that a copy C4
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 tinder#21 remarks section or on the back of this form. ...C.23.Site diagram or additional well details:
4.3
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: ��r
(ft)For multiple wells listSubmit this GW-1 within 30 days of well completion per the following:
all depths if (example-3Q200•and 2@100�
°
10.Static water level below tap of casing: 0 24a. For All Wells: Original form to Division of Water Resources (DWR),
b (ft)
If water level is above casing,use"+" t. Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: ied
aY. .. (n.)Bit Off: 4 Q/5 7 24b.For Injection"Wells: Copy to DWR,Underground Injection Control(IUC) _...
n Id y, Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: � �w }
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the `�
(Le.auger,rotary,cable,direct push,etc.)
county environmental health department of the county where installed p
FOR WATER SUPPLY WELLS ONLY: 7'
24d.For Water Wells producing;over 100,000 GPD:Copy to DWR,CCPCUA
! Permit Program, MSC, , C 27699-1611
13a.Yield(gpm) ,(,2 5 4. Method of test:_�o� A,�'�,� 1611 Raleigh�
'N
70% hth Date Site Visited:V--sy
13b.Disinfectiontype: Amount: ®9 OZ Site Visited By: �T;I .4�`4
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Form GW 1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6 2018
Price: a` i C