GW1--01612_Well Construction - GW1_20240313

r�LL CONSTRUCTION RECORD(GW-A) For Internal Use Only: ; I, Let j ) •1
3
1.Well Contractor Information:s -' + F1q,'l;l ] n j n24 3
I,1%I Now P B lto illiA / 1® 51 e. W:14:WATERZONES'S.,:. ::A,.m:�tx.F.'1D.:'� .. ,:q, n,7. 0F.::�.:;...�.....-"•.1::...:I".4'-t
FROM TO DESCRIPTION.v IfliCirriP ?:".r. !Dr- _ e//a�
Well Contractor Name • IV t%ni V
Cf. 56 6 -A 7,6 7.• ft t.75 ft 7 i griok
c ry:
ft. ft
NC Well Contractor Certification Number a15f0U'1mt C.1SING(foe"•'multi=cssedvians")ORLINERitif:ap"licable)"..; :>;':ems;:.a
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL
• ft. ft i , in.
Company Name Will like) 3 3C-'C•7 B- ?•r_r® i13.61INNEBCASIING:OR:TQBING((;eotlierival`closedLloW;ILI7— •'-:=V•a
2.Well Construction Permit#: /0 C ( ) FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County.State,Variance,etc.) 4. S ft 4 6 ft [.'' 13, , in- SbR '°..1 PVC-
3.Well Use(check well use): ft ft. in.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural °Municipal/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) 111Xidential Water Supply(single) ft ft in. ' -
DIndnstrial/Commercial ❑Residential Water Supply(shared) --• - _ _._._________.._._._._.,.
1 ,GROUTI 1 _ -
❑liiigation - ❑Wells>100,000 GPD FROM TO• MATERIAL `�EMpPIACEMENT METHOD&AMOUNT
Nun--Water Supply Well: 0 ft' 2. ft' i e,,,*' C Pre a a‘ Pow. 16 W? � .
❑Monitoring ❑Recovery ft. ft.
Injection Well: •
ft •
❑Aquifer Recharge •❑Groundwater Remediation r _
i19 SAND7GRAVEIi PACK if ap`pli'cable)s:��r Y .
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO , MATERIAL , EMPLACEMENT METHOD
❑Aquifer Test ❑StoxmwaterDrainage ft. ft
°Experimental Technology ❑Subsidence Control K. ft. '
❑Geothermal(Closed Loop) ❑Tracer ";20:DRI1;*S1VG7:OG`(attachadditional"slieetiti;necnsary)===_w7..
❑Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soli/rock/rock type,grain size etc.)
Date Well Started 0 S-; 1 2 �' 6 ft. 2Z ft re/ ..i ,°,
4.Date.Well(s)Completed:6 0-` Z-2-b We.IITD# �-7( ? ft. ^� ft J
5a WellLocatiogon: • IPhone#: C®4. f�ay® �' ft. U "s ft I:6: ➢r �CzAiralb Li g ft. 1.3
W C
Facility/OwneiName Facility lD#(if applicable) V t• , ft' ' C® ft M Cd y y�.. 1,e r , g P-,a.i 44.
fZ ft
. . •14 -So ,ond� � � 1 ?. �� r apt . r5�-�' �, ..
ty .n d.�0 f t /B s ft e 14 Vic. •S 6 F 4 .._.'ta A•,PLysical�Ad@dress Cn and Zip'
�. ratREMARKS`. ss:ram ,�' 1
•
County. • Parcel Identification No.(PIN) '
. I
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ' ` - _
(if well field,one la_t7long is sufficient) 22,! cation
--y}�
.� N a®,g/�5"2 9, W � � � ".1 �:
6,Is(are)the Well(s): permanent or OTemporary Si_ • e of Certif Well Contractor, I` Date
,By signing this forrn,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or do 1SA NCAC 02C.0100 or ISA NCAC 02C,.0200 Well Construction Standards and that a eopy "5".
If this is a repair,fill out brown well construction information and explain the nature of the of this record has been provided to the well owner.
repair tinder#21 remand section or on the back of this form. 23.Site diagram or additional Well details: o
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-a 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: 8 5 (ft.), Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3(4200'and 2®100)
24a. For All Wells:.Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: �f�� (ft) Information Processing Unit,1617•MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+'� • • _
11.Borehole diameter: (in.)Bit Off: 6 .05 0 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
• Program,1636 MSC,Raleigh,NC127699-1636 ` o
12.Well construction method: a i r fl,,Lt 4-0ar y '
- 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the �,
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
1
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing.bver 100,000 GPD: Copy to DWR,CCPCUA TO
Permit Program,1611 MSC,Raleigh;NC 27699-1611 ,.-
13a.Yield(gpm) ? S Method of test: a_fi r I ; '
o g Date Site Visited: ft-. I y� 7 ,-i
13b.Disinfection type: 7D�o hill Amount: U ® OZ Site Visited By: D ' Ca. Its
Fort GW-1 - unl;..ne artme� nt of Environmental Quality-Division of Water Resources Revised 6-6-2018
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