GW1--00549_Well Construction - GW1_20240125

WELL CONSTRUCTION RECORD(GW 1)L - For Internal Use Only;-:- .1
1.Well Contractor Information:
Jere. (i..3cMC 1?I 5 14.WATER•ZONESaIat,:It•yam...'::.,_.. .,-_---__.L- - .
FROM _ _TO DESCRIPTION
Well Contractor Neale _
2 q. L 8 n 70 ft (yt. COO./( ft. ' ft.
NC Well Contractor Certification Number 'f:15i OUTER CASING'{foF.multi cni`ed':well5):OR•LINFR ini' c)le) . , -'_%w e9ccy111
• ' Yadkin Well Company, Inc. FROM TO DIANIETTER .THICKNESS MATERIAL `�,:T
ft. ft in.
:CotopaayName- -•.- ---•:--
�`P
9 /r 't.16.�3TII1iEIY.CASIIVGORiTUBING`([;e6theima`l.r]med�oSp)�;' '=1W=•(�
' - 2.Well Construction Permit#: / U g J 7 • . • , . •FROM TO' DIAMETER 'THICKNESSIC� MATERIAL. `—
.. _/-/ft S ft. �� fief ;is s d .-a l pi/C
List all applicable well construction permits(.e, IC,Cowiry,State,Variance,ma) �^^ ►Q (Ce
3.Well Use(check well use): tL ft. in.
' Water Supply Well: �'19 SCREEN!:.. `_�L= r . .`, L
PP y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL F❑Agricultural OMunicipal/Public ft. ft. in-
• ❑Geothermal(Heating/Cooling Supply) tesidential Water Supply(single)�` ft ft. in.
❑lndustrial/Cammercial '❑Residential Water Supply(shared) L1a2:GRol)Tc - ••-— = � r,":•••• '
❑irrigation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUN_ ,�
Non-Water Supply Well: 0 ft. 41 IL Noir 91� Pouf
❑Monitoring ❑Recovery 4 f<. ;„)/ ft Qwck Crow% ftmnfeA ti 5 S
Injection Well: ft ft
❑Aquifer Recharge 0 Groundwater Remediation G19P.SAND7GRAVEI;PXCIC(ifrppliMile)1 _ .;e,
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL ' EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology OSubsidence Control ft. ft. '
OGeothermal(Closed Loop) ❑Tracer :i311;DRIL•`G11VGT:OGr(ittiteh`s`dditiona'sLeetiidneceaaty) ^ _ - =�q..
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soillrock type,grain sfzc etc.)
Date Well Started 1'2 t MI 2 3 0 ft. y$ ft. 56
f
' 4.Date Well(s)Completed: 12%7 J?3 Well lD#,44P''7l 4 S ft. 602 ft G ro,n►.'r
Sa Well Location: Phone#61 S./—.�8'2-. t 7 ft. ft.
COK.Y ey Detvis• ft ft a4-.: k r i,�1"�'
Facility/Owner Name / Facility ID#(if applicable) ft. ft
l ,'net fild C1\4 s-l-h A 0 (J8% ft. ft JAN 2 2024
Physical Address,City,and Zip • ft. ft. WOW"' tc.n •7rr..r
a{ .{'71•SRRM.SKRI — _ _ I •1 �'A' .. `."_1:21"�'.
County {"`,GC�e�i Parcel Identification No.(PIN) '
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
30. 7,6a,0 N ! 3 Qf53`C 7 W w i i 11 12.3
6.Is(are)the well(s): ermanent or OTemporary Sigeahu afCcctitied Well Contractor i Date
By signing thisfonn,I hereby cee7tfy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ego I5A 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 nd explain the nature of the of this record has been provided to the well owner.
repair under#21 rematix section or on the back of this form.
, • 23.Site diagram or additional well details: •
8.Far Geoprobe/DPT or Closed-Loop Geothermal Wells having the same ' You may use the back of this pageto provide additional well construction info
construction,only I GW71 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
9.Total well depth below land surface: 6 0) (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)
• 1..::' (e 24a. For Aii Wells: Original form to Division of Water Resources
30.Static water level below top of casing: . (ft) � )�
If water level is above casing,use"+" • Information Processing Unit,1617 Asp,SC,Raleigh,NC 27699-1617
11.Borehole diameter: G (in.) (,,00 7 24b.For Injection Wells:Copy to,DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 2.699-1636
12.Well construction method: 24a For Water Supply and Open-Loop Geothermal Return Wells:Copy to the. '
(i.e.auger,rotary,cable,direct yush,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 '
f`" e` Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) ' It2 Method of test: 1 it
13b.Disinfectiontype: 70% hth Amount: .� O? Date Site Visited: ,�— 2—a 3 Q- '�-,). t
(
Site Visited By: Vii I _
e ,
VI Form GW-I �mental Quality-Division of Water Resources' , Revised 6-6-2018.,.
Priee:�