GW1--06972_Well Construction - GW1_20231027

-.WELT',CONSTRUCTION RECORD (GW-11 • 4r ,
For IntemalWse Only:
1.Well Contractor Information: •
,A:
CC LLIxtiCrift5 C714 WATERZONES •- ....... ... : .. --
WellContractorName FROM TO DESCRIPTION -_
.. 1-1 ^ 4 • ft. Lobo ft l GrM ----. . ..
5.) ft ;Woo ft. ya GrM .
'k•,'
NC Well Contractor Certification Number _15::O TIER:GISTNG(foP mtilti;eukirlieni)-ORLINEW (Ci 1—'- ----
Yadkin Well Company, Inc. FROM To . DIAMETER . na s: _
Company Name .-_
3esssY tt u• t • r:t
2.Well Construction Permit#: 'M TO DIAMETER `�' --
List all applicable well construction permits(.e.UIC,County,State,Variance,etc.)
3.Well Use(check well use): ft. ft. in.
1.7 SC1 r- - -- _ _ _ .".air: 1ZWIt2llneJS o
Water Supply Well: FROM TO DIAMETEr SLOT SIZE THICKNESS MATERIAL '=`
r gricultural ❑Municipal/Public ft ft in. N'''
❑Geothermal(Heating/Cooling Supply) rt}liesidential Water Supply(single) ft ft in.
❑IndustriallConunercial ❑Residential Water Supply(shared) i183.GROI TI"--":''''----"---,=7" ------------------_ __, _
•
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMer.AcTi ElvTMEmonsrAMourrr �1
Non-Water Supply Well: Q ft D1( ft Mole PIuS P*�rea 1P1,_� P'
❑Monitoring ❑Recovery ft. D ft �9
Injection Well: ft. ft
❑Aquifer Recharge .❑Groundwater Remediation ___
i:19:'SA'NDIGRAVFS PACK-`(ifapp calile)i:.. .i _ - .
❑Aquifer Storage and Recovery ❑SalinityBarrier FROM TO , MATERIAL EMPLACEMENT METHOD ~ '
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology OSubsidence Control ft. ft
EGeothermal(Closed Loop) ❑Tracer IL-20:DR11,1IIVG'I:OG(attach'sdditianairsheei;ifirecwary)i .
FROM TO DESCRIPTION(color,hardness,sail/rock type,grain size,etc.)'
OGeothermal(Heating/Cooling Return) • ❑Other(explain under#21 Remarks) ft. 3 9 ft. SO I
Date Well Started '3 I r i t,30
4.Date Well(s)Completed: ci 1r31 a 3 Well ID# AAA 902 39
ft. VOD ft G r 0 0Or '
Phone#: 33 C-'417's2811'q ft ft
5a.Well Location: , . .-,. - _ r ' ,
SA I tt Tree Parm5 CalIe wet( d 3 ft ft - --_'. i.,7 •., f x�L.)
Facility/Owner Name Facility IN(if applicable) ft. ft OCT 2 t 20
23
131144 Reipi l Li.2. sec.r•,l-$O n ft. ft.
Physical Address,City,and Zip ft. ft r _:`••l�.; +,,; i�i Y
A sL a GZL!RFmmuis...w_. 7:fd1:%: - „ a
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field,one lat/long is sufficient) 22.Certification:
3G.Liaas N $)I.1491•3. W - 1fi3 13
.,�,.� Signatiuelof C ed Well Contractor ! Date
6.Is(are)the well(s): termanent or ❑Temporary
By signing this form,I hereby cerkfy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or IfiNo ISA NCAC 02C.0100 or 1SA 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 421 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: '
pp 24.SUBMITTAL INSTRUCTIONS
9.Total welldepth below land surface: OO (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'and 2@100)
10.Static water level below top of casing: '10 rt 24a. For All Wells: Original form to Division of Water Resources (DWR),
(
If water level is above casing,use"+' ) InformationTrocessing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.)B it Off: 4.I S2 24b.For Injection`Well((Copy to DWR,Underground Injection Control(IUC) IA
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: et'VC rQ4,4cy - - Z
(i.e.auger,rotary,cable,direct push,etc.) ! 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
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 01
13a.Yield(gum) 1 6!Z Method of test G::A 1r Permit Program,1611 MSC,Raleigh,NC 27699-1611
• 70% hth Date Site Visited:
.,i b.'Disi ifection type: Amount: 36 OZ Site Visited By: 4 •
Eorni'GW-1 v ',»____ __ __North.Carnlins➢,.. t. nL-nfEpvsrorunentalQuaiity-Division of Water Resources Revised 6-6-2018 iko
Price: