GW1--06848_Well Construction - GW1_20231030

' . jjL CONSTRUCTION RECORD (GW-1) For Internal Use Only: '
W-�e
1:Well Contractorr Information: /-sn
'!C et,(✓(,S.0 \ i{- L'o t t ; '"`+'1;,--,,^.;21•.r1' _„-,;�f:- s�1,.:�:-..�i•'c�,.:__Z.:-_: :,.;',:A.:_
emu.11JJ r i.7ld'';WATERZONES^,a.�. s..`-: .
''..',,::*ell
'�� ' r FROM TO DESCRIPTION - ^,
;Well Contractor Name �� g, apt) ft I- `-
� ft. ft.
NC Well Contractor Certification Number
"I5.'0U'i'r:rt CASING'(fozmiilti;cased;iveifs):OR'I;7iVF�(if:ap'tic'able)i- -Z:.:�,'��::� :
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name a"j .I6i'INNF.R'OASING:011[Tf19ING:"eotlieimaleld ed=loo `r
• 2.Well Construction Pern it# -AO i. 1 6•7 2- FROM TO DIAMETER THICKNESS MA.TERTAI. 1/
List all applicable well construction permits(i.e.WC,County State,Variance,eta) 4 ' ft. SC41 ft G. 1 3.5 in. c 1 t!]- t INC.
Cj `A
ft. ft in
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT 4r7.rr THICKNESS MATERIAL ti
❑Agricultural ❑Municipal/Public ft. ft in.
❑Geothermal(Heating/Cooling Supply) Glitelidential Water Supply(single) ft ft in.
❑Industrial/Commercial DResidential Water Supply(shared) ::18
r,
❑Irrigation =''. ..!i II]Wells>100,000 GPD FROM TO Y MATERIAL EMPLACEMENTMETHOD&AMO
Non-Water Supply`-Weell", ,.... • - /9 r2 ft. a ft N1 t n,Tk aPs /1),J L ,tec, -�
❑Monitoring 0 " ` (4 7023 ❑Recovery i� ft. ft rl
Injection Well: U l ft. ft. ,
❑Aquifer Recharge.- ;1;�r:''_'°•:""I';::I)l roundwater Remediation ___,____ ___. - .7...--
if .s,•,_. :�19aSAND/GRAVEOPACIC'(ifapplicable)1:.- .-- .--_._-__--_--
❑Aquifer Storage and Reccd*r ::'-''`' ❑Salinity Barrier FROM TO MATERIAL KMPLACEMENT METHOD '
r: • ❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft, ft.
❑Geothermal(Closed Loop) ❑Tracer C20iDRIMINGI:OG:(altarc`h`'idditio tirshe`et:ifnec`nsary)":_ _ -.___._."��-
FROM TO DESCRIPTION(color,hardness,saWreek type,grain size,etc.)
0 Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) ft, ft r/
Date Well Started / ryc co''I + 4.oo le A' - -
4.Date Well(s)Completed: fl,/ 5 Well ID# 4 P- 1 p /5 ft p e ft L, t5/-t°Y,J so•,r /( DCA. (may, 44,-0A
,r� : .5a.Well Location:. Phone#:.y 54 Y 7 ea gr ft � i ft /at,......' /k, ( t....y. r t-i ) )
6J� r°�J aces o 3�.�'1T$ ..3 ft �S Leo ft. Coc�w tt!{ (rvrtS� ✓,t/ tr r%7�-�`
!mac®L 1 , lr(�!/J[l �/ ft. 7 it
Facili(ty�/Own (ame' / // Facility ID#(it-applicable)
/ ."a 4.L'eh C.i V e e cc QZ� 4 o gAt'J u it l"� ft. ft. , ,
Physical/Address,City,and Zip ft. ft.
County' - ' Parcel Identification No.(PIN) ...
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwellfield,one Iat/langis sufficient) -.Certifica eon:
�� CMG N p FSC� �' i cW,641/ 5
6.Is(are)the well(s): manent or ❑Temporary Si'�• lg: Certified Well Contractor Date
� iggning this form,I hereby certjfr that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or lJ 15A NCAC 02C.0100 or ISANCAC 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 fo the well owner.
repair under#2I 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 OW-b is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: [ 24.SUBMTITAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3(a)200' id 2®100)
24a. For All Wells: Original form to Division.of Water Resources (DWR), C.
10.Static water level below top of casing: © (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 r
If water level is above casing,use"+"
11.Borehole diameter: 1p (in.)131t Off: /�(�e 05 y
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Arr. A t•D 4--y 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 F.t
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh;NC 27699-1611
13a.Yield(gpm) 5Method of test: V' C
Date Site Visited: fi s 6-(3'2 3
o Site Visited
13b.Disinfection type: 70 a t Amount: I l� OZ By:
North Carolina Department of Environmental lit Division of Water Resources ' Revised 6-6-2018
Form GW-1 P Q� Y