GW1--07965_Well Construction - GW1_20231208

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
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1.Well Contractor Information:
/VA I7-/ems Srti 4,v; u14.WATE?t`7ANES�` ��.;.": I �r •. _ _.. ... 'g• .<u �:-_,_._.:, �?
FROM TO DESCRIPTION °'
Well Contractor Name • e 0 ft. �)i', ft OA !
eft '�1¢t�0 ft......ft...... °/ P
NC Well Contractor Certification Number ;r15.OUTER'CASING'(foRmulti=cased'WellsjARLINF.YZ•(if:iip ltcalilej^ ', °.4%
Yadkin Well Company, Inc. FROM 'TO DLIMETER THICKNESS MATERIAL
it in
Company Name
0< 14
, 16:INNERiCASIIdG.OR:TIIBING:(eotlieimal closed=loop) :_'`_ .�'
2.Well Construction Permit#: �l,� 9(l.� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well consfructionpermits(i.e.UIC,County,State,Variance,etc) IP 1 R• i ra ft • 6 i°P A�/ I'. .SA!- a 1 PVC
3.Well Use(check well use): ft. ft in.
Water Supply Well: yFROM TO Y DIAMETER SLOT Sr717 THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft � .
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) . t• in.
❑IndustriaUCommercial ❑Residential Water Supply(shared) :?IS:'GROUT. - = - :__ _.
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0 ft. .2 a<2 ft 1 e..,4.®�,,e 7t fd. Isn-a�t 6,-,14?s°1d•e� I.6I
❑Monitoring ❑Recovery ft. ft d
Injection Well: • ft. ft
❑Aquifer Recharge ❑Groundwater Remediation i-19:'Se1ND/GRAVEL PACEC(if if licatileTf._ -- ---_--.-_ _ -
❑Aquifer Storage and Recovery ❑SalinityBattier . FROM TO .- MATERIAL EMPLACEMENT METHOD-- ' •
❑Aquifer Test ❑StormwaterDrainage F `� j"
❑Experimental Technology OSubsidence Control f�
❑Geothermal(Closed Loop) OTracer -2UDRI'L•t1NGT:OG•(at}ecliadditionalsheetiiifneciysary)_a_ `...__
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,satl/rorlr type grain size et )
Date Well Started /S 40.„„g 0 ft. d da) ft J'a
4.Date Well(s)Completed: ,1A-Z 2 Wel1113#A,4P eiI! Ito it, Jt/0 ft
W _,,,/ ilia - ...f;/eis&
Sa Well Location: rl Phone#: 33 � � R' �d� t � e ° ,y -1,
ft ft.
•
Facili�i�yq/Ojner Name Facility 7D#(if applicable) ft ft Fs
h 77./r-,,.s ;, c` .t�. -
d Lb5 .��'Ads rid Si ae•J't4 kJ S e ft ft . 4. 'L.r: a _,
Physical Address,City end Zij1� ft, ft n -I T 0 s 2071
A I J 4 4 A/ 3q S(,54 ', i;i21:REl st.'; __: .1 : '(�
County ParcelldentificationNo.(PIN)
Inforrf' lien PrOVE.l�.;g i,t�y;
L'v'v Ll'D-.51
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: '
(if well field,one lat/`long is sufficient) g g{ y� 22.Certification: y
e L9 IO 3c N J9 Yr+¢y73 Y WG% � f�•a ,ram' ®-�6/"
,13
6.Is(are)the well(s): rsr ermanent or ❑Temporary Signature of Certified Well Contractor Date
Sty signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 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. - CM
repair wider#21 remarks section or on the back of this form.
23.Site diagram or additional well details: 4: '
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 .,i
construction,only 1 GW- is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary c>
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 4, S (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3(4200'and 2@100')
(ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR), .e-
10.Static water level below top of casing: Information Processing Unit,1.617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
P w2 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC) 90
11.Borehole diameter: (tn•)131t Off:pp &�r�.i�� program,1636 MSC,Raleigh,NC 27699-1636 6„� o
12.Well construction method: 4/t'• f o'd`'va P 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the �01
(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
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: A'IAl
° Date Site Visited:
13b.Disinfection type: 70�0 hth Amount: 'L OZ Site Visited By: 1
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-201 S
Price: