GW1--06971_Well Construction - GW1_20231027

�L CONSTRUCTION RECORD (GW'-1) For Internal Use Only: '. -
1.Well Contractor
`t Information:r•it lAic'rrCk(05 i.14 WATERZONES
41. 3ee
FROM TO DESCRIPTION �/�
We1lCoatiactorName ft. Z$p ft 1 GPr'i
a $3 A ft. ft
NC Well Contactor Certification Number "15.'0DTER_CASDIG•(for.o ulti-c-a'sedWeIli)ORLINER:Of:4'llcnble) __ ._.-.:.- r
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft, ft in. - - -.. :..
Company Name -._ _-.--
�Jj 16IPII`TEK�CASING.OR�TQBING(geotSermal do5edloop)
Li
2.Well Construction Permit#: ) . I FROM TO DIAMETER THE:MESS MATERIAL
List all applicable well construction permits(i.e.UIC,County State,Variance,etc.) + ?ft. 81 ft to Vgi m• so e,, P lie ."'
it ft in ,
3.Well Use(check well use): _ _
0..VA REElk -- - _:..
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) Presidential Water Supply(single) ft ft in.
❑lndushial/Commncial ❑Residential Water Supply(shared) .;18:-.GROUT_'-_. --. -. - --
❑Irrigation ❑Wells>100,000GPD FROM TO tide
EMMPLACEMENTMETHOD&AMOUNT
Non:Water Supply Well: 0 ft' 3 it tide P(V3 e i eJ 3 6 i S
❑Monitoring ❑Recovery 3 ft. .20 ft CILteic6 o
A Pia vtefPe't 3 •,
r
Injection Well: ft. ft
❑Aquifer Recharge ❑GroundwaterRemediation 1_19.•SAND/GRAVEL PACK(if.appliiable) " _ - • • ._. - •
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL lavreuCEM hiemTHop - 1
❑Aquifer Test ❑Stomiwater Drainage ft. ft.
olxperimental Technology ❑Subsidence Control ft. ft
I
OGeothermal(Closed Loop) ❑Tracer "20.DRITZ NGLOG(attach' sidditio'nal sheets if neceai"ry).-_ .FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,eta)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21Rt'morks) •
Date Well Started 712OJ 3 /y -Dft. /O it 0 n' /
4.Date Well(s) Pa Completed: �1 3 - Well m //#6'4t P / 7 /0 ft' 4.5. ft GPdn ti
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5a.Well Location: Phone#: 1O-- LPafi"179eees. ft• 72 ft Scil
Facility1fl# if applicable) ftt.: 4-r I'. .; V9 1_.."-
ft
Facility/OwnerNamewrit g'4 4 ft. ft
-3 a.aria ft®e /tr 16 o, AO , O C T Z 7 2_ 3
V L J
Physical Address, g� � ft ft L it2
City, � 21:`11F.NLkRKR. - - _ -; - .-.-. 3v.-,.s::•*,'31 U1:I.-
County Parcel Identification No.(PIN)
5b:Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IaUlongis sufficient) 22.Certification:
3c Z tee VI 9(0 N l 2.7 3 ' �°'i W Q �}. � of 2 3
>r Signatur of Ce ' d Well Contractor Date
6.Is(are)the well(s): ifermanent or OTemporary[(1� By signing this form,Ihereby tern;fy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or tNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out!mown well construction information an 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: J 40.,2 24.SUBMITTAL 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 tfdifferent(example-3(g200'and 2( 100) •
24a. For All Wells: Original form to Division of Water Resources (DWR),-
10.Static wafer level below top of casing: 30 (£1) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" •
J.
24b.For Injection Wells:Copy to DWR,Underground Injection Control(MC)11,Borehole diameter: Cln•)git Off: ����� Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: rot r -LQ V' 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
a Permit Program,1611 MSC,Raleigh,NC 27699-1611- 1
13a.Yield(gpm) I Method of test: 0/V r a.k 13 f
o Date Site Visited: _1 -..k
•
f • 13b.Disinfection type: 70�0 hth Amount: OZ Site Visited By: V ,,
Farm GW-1 N�rrth Carolina Department of Environmental Quality'-Division of Water Resources Revised 6-6-2018
Price ,da � � �� Qd
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