GW1--08004_Well Construction - GW1_20231214

� 'LL CONSTRUCTION RECORD(GPI-11 For Internal Use Only:
• I.Well Contractor Information: II
Cr o Gf sQ j vs,t •A.)4 _ -r I S.X%i'W.A:TE ZONES , rg:i. m^:;�i; l .2 "?v;qs.1- . : >-;.i; :v 05
Well Contractor Name I P t..'C '. b• +t1 ..., \ �! FROM it TO ft DESCRIPTION 1.
no
/35
3D3 5— DEC 1 202) 13S ft• 3116 ft `f,x1^6, a
NC Well Contractor Certification Number 115 OUTER:CASIIQG'V6Fiiiulti,cased veII.i").ORIJNER'(ifap licalile) �" :r.5'2 r
Yadkin Well Company, Inc. �,- �. �;�,r> i_! OM TO DIAMETER THICKNESS MATERIAL
Iri,�a • ft. ft ' in. /�
Company Name a 'L.V _._. .__
0 �y/''� 116i�]P11�7ERCASING:O1teTIIBING:(ge'otlicimal:clos3=Ioc'p)«j:5`", - _..u.;i?:4
2.Well Construction Permit#: 9 c1 R, 0 FROM TO nr. S DIAMETERry CERESS MATERIAL • ,
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) + l ft. ,99 ft 4,05 S ?.9) (°'u
3.Well Use(check well use): ft. ft in. _
Water Supply 7,:7:.CAV i.� . - '_' -,. - - - -
PP Y Well: FROM TO DIAMETER SLOT SIZE THICKNESS , MATERIAL rie
❑Agricultural ❑Municipal/Public ft. ft. in. ($
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft In. 7
❑Industrial/Commercial ❑Residential Water Supply(shared) ;'18 GROUTt �` :'` —
❑Tai ation" ❑Wells>100,000 GPD FROM TO MAT�t:^.ERIAI.W' EMPPEtITMETHOD&AMOIINT
Non-Water Supply Well: 0 ft ®
ft dad- 6,1,5 Q, 104ee_
❑Monitoring - ❑Recovery ft. ft.
Injection Well: •
ft ft •
['Aquifer Recharge .❑GroundwaterRemediation �.. �_ _
ica9..SAND%IRAVErTACK'(if applichlile);:. TM - . '7.1 i .
['Aquifer Storage and Recovery ['Salinity Barrier FROM TO ' MATERIAL EMFLACEMENTMETHOD '
❑Aquifer Test ❑Stormwater Drainage n• ft ,
❑Eicperimental Technology ❑Subsidence Control ft. ft - '
❑Geothermal(Closed Loop) ❑Tracer w20:DRICSIiNGI:OG'(a"tta`ch"idditianall`sheeteif.neeessary)i' p'j. . ..-•
DGeothennal(Heating/Co ling Retpm) (explain Remarks) FROM TO DESCRIPTION(color,hardaessysotllroek type,Ream size,eta
❑Other lain under#21 r � '
Date Well Started /b ® /9 D . ® ft.
®i,�t �`, l fy 5 ,. ®;e.'
!I:Date Well(s)Completed:19/ 9 3 Well1D#fi'('f' — 90 3 ;.`- o ft• , tt 11(ep II •(�y,ev.5 1 66..y' e c.y
Se.well Location: Phone#: r el or 1^7 16(. I P ft. `�- ft .c.f� r (i-v, J4' CA
P $rt fi�Q.H° T.[ • ®G� I RySterj/
Facility/Owner Nam ty
e Facility • � r�'ft %) ft 11,2' kt Leeyty,5 J G',ti,A-1 —pied_ii,
Physical Address,City,and Zip /('`�' /� ' ' ii59 _
ft
- County Parcel Identification No.(PIN) •
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:,
(if well field,one lat/long is sufficient) 22.CertitieSo:4..44i i, 1, - . ..
3‘.4. /Y-3cg- N Tri. 02'Yes' .v \-...„...., :,62;;,,,,,e . .
p
6.Is(are)the well(s): fi ermanent or ❑Temporary of Certified Well Contractor ' ate
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 II< 't 15A NCAC 02C.0100 or 1SANCAC 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 Mil form. ��
P 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 di
9.Total well depth below land surface: y (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q200'and 2(4;100) e.'
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: Cr, (R•) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing;use"+" r
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in•)Blt Off: Program,1636 MSC,Raleigh,NO 27699-1636
12.Well construction method: f"1 e If R offary 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: 8� 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
1 Method of test: ff"1 °p Permit Program,1611 MSC,Raleigh,NC 27699-1611 se"�e-0,4,,�,i{
13a.Yield(gpm) ice' —2_
o Date Site Visited: B� ?^(7-2 , it
. 13b.Disinfection type: 7��o hth Amount: 1 6 OZ Site Visited By: 1 03
0573 4•-®C-2 3
Form GW-1 _ North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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