GW1--01678_Well Construction - GW1_20240315

',.%WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: i ,
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1.Well ContractorvInfor�'m_a ion: � I I
Cl CI v I.I I(li to IN')(A / 1( ) I d' :
.�.14 FVA1T$7ANES w.:':5'_'::NC3-":u3.'`1W-1' :'': -.....:%F,'i'.4'•,`: i:�5..'S=.'P..:%t, >r'7r�d'aFROM TO ,,DESCRIPTION e•
Well
Contractor N e it ft H
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NC Well Contractor CertificationNumber 6.ja
615::OIISEICCA31NG'(fot'multi=casedVelICORLINER(t£ap Ellie)".: . 3'_?'n? ch
Yadkin Well Company, Inc. FROM TO DIAMETER, THICKNESS MATERIAL
4. l ft. 13 ft 60'01 in. sUI`-11 PVC
Company Name , . ----- j
816°INNER�CASING OR.TUBING;(ge ittier iiircIosed:Iuoffc;I -- eta='
2.Well Construction Permit#: e. 01?9 2. 2,3 FROM . TO ,DIAMETER THICKNESS MATERIAL
List all applicable well construction permits WC County,State,Variance,etc) D it m -
3.Well Use(check well use): ft. it : in.
Wat Supply Well: s.J 17,5C :27:=.•"�,�.._ t ':: '_� _`� �: ` 2: "
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
'cultural ❑Municipal/Public it. ft in.
0 Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) ;18.GRbUT.`.;=------_--.- --__..--.___e-._-__-_._..__-_-.T✓
❑Irrigation ❑Wells>100,000 GPD " FROM TO MATERIAL EMPLA EMENTMETHOD&AMOUNT
Non-Water Supply Well: • 0 it, 7.0 ft (1 Q,1 4` C l,I p 5 ,906,r I1 71 j r
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft I
❑Aquifer Recharge ❑Groundwater Remediation
i 19:•SAND/GICAVELPACKC(ifapplica)ile)"s'" � .`�_=11: ."
DAquifer Storage and Recovery ❑Salinity Bather FROM TO MATERIAL 'ENEMA- CEMENrMETEOD -
❑AquiferTest ❑StormwaterDrainage . ft R' 4 -.r i VJ "i`
❑Experimental Technology ❑Subsidence Control • ' ft. ft. I MAN) r 2 n?,A
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❑Geothermal(Closed Loop) ❑Tracer ., C20MRTI' NCB:OG(iiit'a'ch`'a'3ittilki`1sLeet's:iEneeeis1..-!'..:1_ l;c-r --
FROM TO DESCRIPTION(color,hardness,sail/rock type;grain size,etc.)
• ❑Geothermal(Heating/Cooling Rettun). ❑Other(explain under#21 Remarks). tn,.:�r�.:�.;c ;�r;- o
Date Well Started 2-2'�-2 , ft'.
L 9 3 ft [)i •i-d-f•1 , 'e('P,� e3 ;?a l�.
4♦Date Well(s)Completed:1-i9'7K WelID# A.-4 ""?g 7 1 6 ft ill f. 4'PF, *ee. i� 6c.,.�'y . ' r
Sa.Well Location: Phone#:316 .7§�/ 3t� ft ;�If 0
it �c•d i1-h.... !-N. 41; Mt( �•:)% ;'. -• ,
�- H I ft. 2 ft. j J I 1 T ^fin 4' .• 1, N' `'t,.
?illS1 A 41rabiepl, SAS r� -`" = .
lity/Ow-�nerName Facility ID#(if applicable) 81 1 rt It"t L21 fr. ,D-($ 1- 1O Ql�s.- C:i. 4-.�rc�;; . •
(ro f a ppILd lv la z.h v i l 1 e ,a1®.\\ ft. ft `f
Physical Address,City,and Zip i' ft. ft 1 -.-!:-.:,-;.i,
�,t i•21 FEmAlacfis-`.'_`.v v._..r�:�=". :"�..._.---- ."� ��-__._ ...:::.:`.i`.�,'
• 'County Parcel Identification No.(PIN) Frock II. ra,i,.r 1-e.d R66 ` --�ez'1 ' •
1tn4'
5b.Latitude and longitude in degrees/minutes/seconds or deeimal degrees: 1 4-N si-1- 'iJ `t'�n e 'ae46
(if well field,one lathing is sufficient) 22. •. tification: '
e.
3,6 Z/62-l°' N .a0,96 'Of,. w: � :Cif.. ' 0 d7' 1tJ //v!� �• a`�Cl/(�,®(
s z- -
6.Is(are)thewell(s): permanent or ❑Temporary Si;'t' ofCertifi eilConhactor j Date
S By signing thisform,Iherebycertify that the well(s)was(were)cci structedinaccordancewith .� '
7.Is this a repair to an existing well: DYes or Imo ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy 5:
f 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: CY'
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.SUBMTITAL INSTRUCTIONS
1, J �, .?
9.Total well depth below Iand surface: 9 I it
i t-3 (it) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells Iist all depths ifdifferent(erample-3Q200'and 2Q 00)
1.
i 24a. For All Wells: Original fo to Division of Water Resources (DWR),
10.Static water level below top of casing:-'; (fi). Information Processing Unit,1617I MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"/ 4.1,'"
�
(� (in.)Sjt Off: S. 9 U`7 24b.For Injection Wells:Copy to;DWR,Underground Injection Control(IUC)
11.Borehole diameter: //� Program,1636 MSC,Raleigh,NO27699-1636
(12.Well construction method: ° [ Ur.r u i,Y LP
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.
I • �
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
/ i Permit Program,1611 MSC,Raleigh,NC 27699-1611 �.
13a.Yield(gpm) '> Method of test: Nfe ,Are
o �� Date Site Visited: G'��- � �` "� �r b
13b.Disinfection type: 7��o hth Amount: 6 Oz Site Visited By: DZ4 ) I S-���(C I ei ��f 4.
• i ,, C.L. (.,,c0
.. Form GW-1 11_4 Carolina Department of Environmentat Qualit L-1Division aLWaterRecnnrcec. _, Revised 6-6-2018