GW1--06861_Well Construction - GW1_20231030

•
WELL NSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
_ ..Necci LA)a5rkt.ns 1;.14i'WATER 7.ONES`.".-_.•c::_�':;_:.-,:
FROM TO DESCRIPTION
Well Contractor
Contractor Name g, t 90 ft 1 G7
]yssA ft ft I [ �
NC Well Contractor Certification Number :15:'011TEIt CASING(fo%:mulfi=casadWial4)'ORI.1NF C('dn"licali.103- _-_ -.
Yadkin Well Company, Inc. FROM TO DIAMETER IECICNESS 1 MATERIAL
ft ft. in.
Company Name - -
��� ®� Sfi]III4ERCASING:ORCTIIBING:(geotliermaldoied;Ioop)7>z._�= _
2.Well Construction Permit*: FROM TO DIAMETER THIC m ESS MATERIAL
' List all applicable well construction permits(ie.UIC,County,State,Variance,eta) a`ft. a i t /LI siti in. 3 p�'1 f;
•
3.Well Use(check well use): T t ft ft in.
d]9:
Water Supply Well: SGR ------ '-- �_ — -- -—
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ,❑M/unicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft . ft in.
❑lndustrial/Commercial /❑Residential Water Supply(shared) y 48 o _ "-: -—^ -__ - _
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT-METHOD&AMOUNT
Non-Water Supply Well: v ft. 3 ft. fv le p(,3 Foam;:)) 2 6a ys
OMonitoring ❑Recovery 3 ft 2 ft (lock 6e04 P,,,irer1 3 644E
Injection Well: ft. ft.
❑Aquifer Recharge ,❑Groundwater Remediation
1"19 SAND/GRAVFLPACK-(ifapplicable);_: ^_yam- -. _:_._._._.__ . , .
❑Aquifer Storage and Recovery ❑Sal inityBarrier FROM TO MATERIAL EMPLACEMENT METHOD '
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft
OGeothermal(Closed Loop) ❑Tracer '•20DR$IIlVG'I:oG:(itiiarr ditionanlieetiifnecei's`iry)°::_.___._=�_J-:__.__.:
1�etum) Clther(explain under#21 Remarks) ,.
TO DES ON(color,hardness,soil/rock type grain size,etc.)
(Heating/Cooling
Date Well Started q f 2�+23 „0ft '3 ft
4.Date Well(s)Completed: 9126123 Well ID# e' L h 3g ,'3 ft 302 ft `<cav l-( 0
Phone#: 5 -1746rf-.5- 14 ft ft _ ;
5a.Well Location: J ;
/ C /` J DS v1 dIL 9�IN.e.o ft. ft 5 .' .,-. :
_ I ( .0 e, ( tP j/'O(( l)J"6ll,(1G'...d<th7Si� .�'�._.i i s .
Facility/Owner Name 4 Facility 1D#(if applicable) ft. ft OCT 3 0 ' 0 2 3
P i `'C..y .J h a,1 e /Y 6i9 i1t O 1a®-1 ft ft 1 1 :`1 ..
s. ft ir.; r , . . i .' J
Physical Address,City,and Zip .
County Parcel Identification No.(PIN) '71
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
3C hi, 1Z ‘�N 8I 3S, S137 W W 4136(a3 ,
6.Is(are)the well(s)
s: ermanent or ❑Temporary Signature CeRifie well Contractor Date
(
]],,���. By signing this form,'hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes oro ISA 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 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 ofiii is 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: 3 D? (f') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths tfd fferent(erample-3@200'and 2(4)100) -
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: !1 TO Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" -
11.Borehole diameter: 6 (in.)Bit Off: 6.01 O 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
1 Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 6 ( Gll'L/ 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(ie.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 DW12.,CCPCUA ,.
13a.Yield(gpm) Method of test:_ t�c,(/ Permit Program,1611 MSC,Raleigh,NC 27699-1611
70% hth Date Site Visited: 4.- 1 ir—a 3 W
. 13b.Disinfection type: Amount: g OZ Site Visited By: V . -mod
Form GW-1 Nndh lin.neneromentofEnduonmental Qua tty-Division of Water Resources . /- 'Revised 6-6-2 8
Price:7