GW1--06968_Well Construction - GW1_20231027

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: l •
1.Well Contractor Information: , , I
.Se•rel WC/4ktwS : a::WATERSONEs,1L."251- 1. _2 w._�=_._�_,~ 2__��__:.:�, -
Well Contractor Name
FROM TO • DESCRIPTION~
• ft. NO ft S GPI
P4-I S."A ft 2 So ft /0 oPfai
NC Well Contractor CertificationNumber 11S::O1JTEi CASING'(fo'r aiilti=cased vells):ORLINER:(if,'a'p"livable) "^^::
Yadkin Well Company, Inc. FROM TO DIAMETER TRIMNESS 1 MATERIAL c-
ft. ft. In. C.
Company Name 'w165INNERRCASING:ORTQBING;'(geotlie`r`marelcis d=loop)7: rc
2.Well Construction Permit#: 3 a S- I FROM TO DIAMETER THICKNESS MATERIAL~'-.:. •5•.
List all applicable well construction permits(Le.7JIC,Count",State,Variance,etc.) ,-., I ft' ,AS ft G Si* in. • 188 c01 1 4/ - 1
3.Well Use(check well use): ft. ft in.
;Cri;Supply Well: �17'SCRFiED1." `-`._---�. .
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
cultural ❑Municipal/Public ft ft in. 1
❑Geothermal(Heating/Cooling Supply) . Residential Water Supply(single) ft ft. In. ",
❑lndustriallCommercial DResidential Water Supply(shared•) '18�GROlI1 - , ` _ �(11
❑hrigation ❑Wells>100,000 GPD FROM TO - MATERIAL EMPLACEMENT METHOD&AMOUNT i v
Non-Water Supply Well: 0 ft. ,. Q ft 1 1e t�P1 90V ' „-53
❑Monitoring ❑Recovery ft. ft
Injection Well: ft. ft
❑Aquifer Recharge 0 Groundwater Remediation
i_19:SAND%GRAV1;livPACK"(ifapplic`alile)122=1.1==: w=`„ . -i
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD - Th
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology DSubsidence Control ft. ' ft 3
❑Geothermal(Closed Loop) ❑Tracer !;20 DRITShHGX:OG(atta'eh additiowt sheetaifneceasary)��� =__-
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soWrnck type,grain size,etc.)
Date Well Started cVet D3 c 0 ft. - 5 ft. -Cpe
4.Date Well(s)Completed: I (23 Well ID# ,4/A�-7�� 7 S ft Li yt. G can`\
Y
��rr5aa.Well Location: Phone#: ft. ft i
$4' 1.1 T r42. FoU'MS W q!'c h O LIS 0� ft. ft. ,-- , 7---C.; i "�'^',
Facilit)�/ wner Name cc Facility ID#(if applicable) ft. ft `.. _•i, 4,:.``
f
ft
Physical Addres ity d Zi� o �z �sv4 f ftt. J C T 2 7 2023
County Parcel Identification No.(PIN)
c ` op.3::
5b.Latitude and longitude hi degrees/minutes/seconds or decimal degrees:
(Ewell field,one lat/long is sufficient) 22.Certification:
36 '' N JV Jr ,' I+Oh w tAratt 9IijD3
6.Is(are)the well(s):X ermanent or ❑Temporary SignaturelofC ed 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 or XTo ISA NCAC 02C.0100 or 15A NCAC 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 to the well owner.
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GWA1 is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also attach additional pages if necessary.
drilled: 1
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: , 4 4D ft.
For multiple wells list all depths if different(example-3@200'and 2Q100) ( ) Subunit this GW-1 Within 30 days of well completion per the following:
10.Static water level below top of casing: 10 ( ) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in.)13it Off: i j d• 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC) 2
Program,1636 MSC,Raleigh,NC 27699-1636 <
12.Well construction method: Cq/r r0 `tz.r! 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
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA LP
13a.Yield(gpm) I S Method of test: r, eV r
Permit Program,1611 MSC,Raleigh,NC 27699-1611 i
70% hth ®� Date Site Visited: 681/G/ 3kjt ®. 13b.Disinfection type: Amount: i i Oz Site Visited By: �vai,6
Fern GW-1 1' Norlh Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018 y,a,
v '-- --,. z _l
Price:
1