GW1--00546_Well Construction - GW1_20240125

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: i
1.Well Contractor Information:
/14 l 1 14.G1 I ` ,e E14 WATER,ONES`:.__1- j;':- z :'.:.._ ,..^!: , .; -
Well Contractor Name FROM TO
/� DESCRIPTION
f�� fO �t¢ ft
NC Well Contractor Certification Number 3 I ft 3 Ci Lift. 'i ,M e
7.15:OUTERGrASING(fir mulH=cas Neils)ORLINF.R(ifs"licablie)<;:,".=-
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS 1 MATERIAL ` ``-
ft. ft. in.
Company Name .\--
;!16iINN1ERCASING:OR'.TUBING:(ge llifilal'do§ed:loop) , :<._�a,: :
2.Well Construction Permit#: / f��j `�5 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,,County,State,Variance,etc.) . 'It. i c!ft /• /2s in• f o,a.rs�f/ ()V(.i C;
3.Well Use(check well use): ft I ft• ( 1 is r
Water Supply Well: .]..7:SGREEtI::.,G�.._�.F;7;r�i":1,'�i- I:Sc;., :_..',�,_---s.: -'
FROM ED_ DIAMETER SLOT SIZE THICKNESS MATERIAL `1,...__
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) -rl'esidential Water Supply(single) ft. ft -. ----...
❑Industrial/CommercialFo
❑Residential Water Supply(shared) -.18 GRour : :-. -:'--;-:=t"..-..: �-1
❑Irrigation ❑Wells>100,000 GPD FROM TO " MATERIAL M1 ECM-IPLACEMENTMETHOD&AMOUNT jc,
Non-Water Supply Well: c� ft. °�© ft. ''3e1,k,.1 t itt a yid S D U✓s�L� "'��
❑Monitoring DRecovery ft d� ft f 17 I S
Injection Well: l
ft. ft
❑Aquifer Recharge ,❑Groundwater Remediation ___
191-SAND/GR`AVP L I'ACK-(sf npjtlicable)::.2111t _ :ac:: .==.i.__ -. _ ..
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM _ Tp MATERIAL EMPLACEMENT METHOD ' '
❑Aquifer Test ❑Stormwater Drainage ft ft. `-s--..
❑Experimental Technology ❑Subsidence Control ft. .' ft.
❑Geothermal(Closed Loop) ❑Tracer 'i•20':DRI7t`II1VG?I:OG'(attac'1il'lldition'anire'et-s'ifae"c'e's'se"ry)r;•=7: ".. ',7?-7;:c.:2 '.
El (e:nplain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillrack type Praia she etc.)
❑Geothermal(Heating/Cooling Return)
Date Well Started f)-(1- IS 0 ft (IS- ft ,Y'o t)
4.Date Well(s)Completed: )3,-13-2_3 Well m# P®f&, rft. 154. ft. 5o fir
5,c,...7
sa we�l Location: Phone#: 17j 1 -if 4 113 ` (Sift s v..ft , .f ✓df- �, , ,•. t
`d9 C®9 ✓P ®t$.i+ "A�s�L' ft. 1 ft.
Facility/Owner Name/ ii Facility ID#(if applicable) ft ft.
iJ/14 ' f X-6ve ovef 4 ft ft. 5 "" ,
,� a l4d i ate"'
Physical Address,City,and Zip oa J ttir ft. ft S 1�' '�I.-..,1 fit- )
�Aefett •.21a'RE114AR$Sf•.,.�. ::, ..:,.. :JAN:.,n= )'-:;I:__.,-
A e1 (UC 4
ParcelIdentificationNo.(PIN) ( r
County +' r"r n::is,l t5.,'.-.�cS,,.,,,
sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Dt'.i. 'C . -a E%tt.'1
(if well field,one 1at/long is sufficient) 22.Certification:
. 7 ZiP 1. N / Z a a O SA,' w971,40&;) E - = a- 13--a23
6.Is(are)the well(s): "Permanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby tern;fy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 0 15A 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 ad 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: I 24.SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: `7� (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200 and 2Q100)
/j! 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 3��/ (ft') Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: 6 (in.)Bit Off: .5. ?Ill 5 24b.For Injection Wells: Copy to DWR,Underground Injection Control(ItJC)
Program,1636 MSC,Raleigh,NC 27699-1636 ��A
12.Well construction method: Y19 -a ix), 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the Y+
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed 7.
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA 1
t Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) S Method of test: , I • ��
o �1 e Date Site Visited: /D-- ���a c,�
. . 131i.Disinfection type: 70�o hth Amount: OZ Site Visited By: 1 - .z`,
/� kaCX
Form GW-1 b lin a o De liment afEnviranmentat Quality-Division of Water Resources i Revised 6-6-2018 Jr
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