GW1--01620_Well Construction - GW1_20240313

u —WE' CONSTRUCTION RECORD(GW-1) For Internal Use Only:
S. 1.Well Contractor Information:
'S5 - darn<s bt 1.14?.wADM•zoNES±1 _ai-.:fi z.-_.-'i.::.'z i:. :,.:...ZE_':?1,:. K`.�;.._7 :'•[ice ./?:.e t
We1lContractorName FROM TO DESCRIPTION
�16t® /- C1 ft. a4 ft Ir�,f&I / 1 ypM.
ft ft
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NC Well Contractor Certification Number
ris..0I at.VASING-(fOtatilts=ci'sedwells)':ORLINEIOif:ap`licabt42-1::._7.1-
Yadkin Well company, Inc. FROM i TO ir DIAMETEI' THIC[ SSs MATERIAL
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Company Name „.,,.Q�y '$:16 t t :I•'CASINR:T[7BING;(gediliesmal'closed=ldop)�t'�=�_`_:'.�,s_,�:t`
2.Well Construction Permit#: 3 tL /5 -'~I FROM TO • DIAMETER TRIMNESS MATERIAL-
Listen applicable well construction permits(Le.UIC County,State,Variance,eta) 4 ( ft Lei it 6./.1S in. ‘CI
V 2 i Ki•C
3.Well Use(check well use): - ft. ft N' in. tD
Water Supply Well:
FROM TO DIAMETER SLOT THICKN S MATF.I21'AL
❑Agricultural OMunicipal/Public ft 7 ft in.
❑Geothermal(Heating/Cooling Supply) Vesidential Water Supply(single) ft ft in.
OIndustrial/Commercial ❑Residential Water Supply(shared) ;18, o —---.— :_j`_ i -^_- _.-___._...
❑Irrigation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 'i 0 C ' -s 12,b4 S
❑Monitoring ❑Recovery ft.- , ft s '4 L.a"'
Injection Well: r: �,� ;
❑Aquifer Recharge .❑Groundwater Remediation ft MAR 1 � (n}
l`19 SAND/GRAVEIiP,AGIC(rf'applicible)''__�. _ - -. -ZU '
❑Aquifer Storage and Recovery ❑SslinityBarrier FROM TO MA EMPLAel ,is METHOD ' •
❑Aquifer Test ❑Stonnwater Drainage 1,r,v
❑Experimental Technology ❑Subsidence Control ft. • ft. -
❑Geothermal(Closed Loop) OTracer 30:DI2ITT7NGIAG`(a'ttacliiidditianal'sheetaifneeds-iyl ____._-._.__.._.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,sotllrock type grain sire etc)'
Date Well Started 0 6-'tL 0 ft, 6 ft. ,,o.'� -
4.Date Well(s)Completed: 6 2`7—2 al Well ID#AA 6 21 CS ft i t i Oft. A�'L. Iv co- �� ;
5a.Well Location: Phone#: Fl ed-�52 6 **ft_ i IZ ft' 9 115 lead-, fah- 6�• •1 ,4-
- , 117 ft. 2 00 ft p be, ��c.1-- = S®qa
Fao''tyy/ weer Name , Facility 1D#(if applicable) 207 ft Q/(�:L,ft . .416,4
' Gjiv.y co .
6e1 hi C1�1 e e/ Boon i~ ft ,7(� ft 6,}p 4-• ✓
Phsica1 Address,City,and Zip d ft ft
to' &tf>14c9fp.. igendl✓ ?,• e7 Lt 4 4+ '5. .. •
County Parcel Identification No.(PIN)
5b.Latitude and Iongitude in degrees/minutes/seconds or decimal degrees: .-(if well field,one lat/long is sufficient) 22,Certine 'on�1
. 34,, a 3 .H.S N 81, C,d 1 11 W O2 i-2 c(
6.Is(are)the well(s): ermanent or ❑Temporary Signature of Certified Well Contractor Date er
By signing thisform,I hereby cert jy that She well(s)was(were)constructed in accordance with Lyi
7.Is this a repair to an existing well: ❑Yes or To ISA NCAC 020.0100 or'ISA NCAC 02C.0200 Well Construction Standards and that a copy t-f
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 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: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 30 (ft') Submit this GW-1 within 30 days of well completion per the followings
For multiple wells list all depths ifdifferent(example-3Q200'andd 2Q100)
10.Static water Ievel below top of casing: Q'(® (ft.) 24a. For All.Wells: Original form to Division of Water Resources (DWR),
Information Rrocessing Unit,1617 MSC,Raleigh,NC 27699-1617. C91
If water level is above casing,use"+"
11,Borehole diameter: (in.)git Off: U
�•73 @ 24b.For Injection'Wells: Copy to DWR,Underground Injection Control(IOC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: A rr, 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
FOR WATER SUPPLY WELLS ONLY: • 24d.For Water Wells producing,over 100,000 GPD: Copy to DWR,CCPCUA 4
Permit Program,1611 MSC,Raleigh,NC 27699-1611 LP
13a.Yield(gpm) Method of test: A r Y _
hth Oz Date Site Visited: I
t
13b.Disinfection type: Amount: Site Visited By: I
•
❑....,,r:W_t - - North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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