GW1--02305_Well Construction - GW1_20240410

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WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only:
1.Well Contractor Information:
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aAni'Gj (4&.t t .f4!'.WA.TEt2'ZONES 11: ::,:':.. i..; :�
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Well Contractor Name FROM. .TO _ �,
..DESCRIPTION
Lk to A1 3 (loft. ).qlt F «3..-.. - ,roDAeN- d-st resi_6,
ft ft
NC Well Contractor Certification Number -' '
;:13?OUTER:C:9STNG'(for`mti12i:c`"""esed;iveIIs�`:OItTA,VEIti(if.•a"•7i ale)„=ii• '::
Yadkin Well Company, Inc. FROM TO/ D TID: s 1 MMA.TEItr¢�'
ft. / ft in. /
Company Name 111
1 1)4 :S6yINNER.GSSING.01:MDBIN•G`�'e'otheiiial closed:1 a it.-•y s 1 li iznl
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2.Well Construction Permit#: U, FROM TO • DIAMETER THICKNESS u MATERIAL
List all applicable well construction permits(Le.LI1C,Comity,State,Variance,etc) + ft. tff ft 6,/ 7 e m- Scl/ 2 ! P p _
3.Well Use(check well use): I ft. it I fir' in.. (
Water Supply Well: E 7'S.C.TE r;.:'- ..i -....::s a_f.' "slit ma `s::f-,rs.'•1:::° :::iz ..2i:.-�`.:::5:e'1_z:
FROM TOi- DIAnxER^ SLOT SIz yTHICKNESS MATERIAL
❑Agricultural ❑MnnicipallPublic t / in. /
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft t 1 !n. l/
❑Industrial/Commercial CoResidential Water Supply(shared) i 18 aftvort" ...._; =• -;'.. L.:•i w '• '^'T..':.'
❑Imgatron DWells>100,000 GPD FROM TO MATERTAT EMPLAC mxtiFA&TROD&AMOUNT
Non-Water Supply Well: ft.
cy ao ft 1 11(�.'�S likely f41/ ( 2 b(5S.
:Monitoring ❑Recovery „ ft. ft
Injection Well: • •
'' ft. ft
❑Aquifer Recharge ❑Groundwater Remediation .
i il9:.SADlGE A-VE lt.ACKf(it}}q`lic1ble)=.:;<'l;:•'•:`' C' r __ :.+Fs _.,. .
❑Aquifer Storage and Recovery DSalinityBarrier FROM • TO MATERIAL EMPLAN METHOD'e':
❑Aquifer Test ❑Stormwater Drainage ft
/,
DExpe imental Technology ❑Subsidence Control ft / ft .
0 Geothermal(Closed Loop) ❑Tracer • '20:DRTfii1 GTAG(stficli additigiMilieeti$ire-ceisaiy)" _ i. •;- ,S:37••;;! . -
❑Geothermal(Heating/Cooling.Retnm) '❑Other(explainunder#21Remarks) FROM TO DESCRIPTION(color,hardness, grain. size,etc)
Date Well Started .$� 1 .. ra� ft / ft d
", .f I ®� 9
4.Date Well(s)Completed:3-2*-2.tf Well m#A ft. ft wi-
Rhone#: d ft. ft r .
Sa.Well Location: ��.� .. �.� . �Oa
f fl �.�® �� iRi'r a-y .i!/��/�--L
LG�.�r c)S '�' - ? ft. 2 y it 15 d► 4114,1-e Vacci- Sow
Facility/o&erNa1m1e ' cc Cr
,�` p�. Facility M#/,1(if applicable) �'2((ft Joe}. it b yq- �t f'j,p1� wd •
3 b. �IO�Q/'U J' '�/° telt (4j •P. U .UO©no,r f. •f.,• 4 vF�Y
Physical Address,City,and Zip �b 0`�. ft ft^ i }rrrr. . :•`",(�:y': T.
I, f.1:111 1yaRES .,,..._ ::-Ii• t •. .:'•- ,:> �'.(s' ,.-• it'.:1; .ti 7a.a.
-4M �:.+fll v /t
County' • .,. . . Parcel Identification No.(PIN) NydtO APR 1 9 2024
5b.Latitude and longitude in degrees/minntes/seconds or decimal degrees: t 0 3 A LAre. eeet 14,
(ifwellfieId one lat/loagis sufficient) tray:-r;:l.D :-'.-::ti 44-;s: U •
�� • .,p 22.Certification: .D r Q/::) J 2 P�
1 3i?
6.Is(are)the well(s):permanent or _!]Temporary Signature of Certified Well Contractor Date
By signing this form,Thereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or XTo. 154 NCAC 02C.0100 or 15A NCAC 02C.0200 Weil Construction Standards and that a copy
If this is a repair,fill out known well construction it foriaation and explain the nature of the of this record has been provided to the well owner.
CP
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 I GW-1 is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box).You may also attach additional pages if necessary. in •
drilled: - 24.SIIBMITTAL INSTRUCITONS 3
9.Total l depth below land surface: ®U ,� (ft) Submit this GW-1 within 30 days of well completion per the followingi R.
For multiple e w wells list all depths if different(example-3@200'and 2@100')'
10.Static water level below top of casing: 2,9 C (ft.) 24a. For All Wells: Original form to;Division of Water Resources (DWR),
If water level is above casing,use."+"/ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (6 (in.)Bit Off: ;,163 24b.For Injection"Wells: Copy to DWR,Underground Injection Control(TUC) ... .,
Program,1636 MSC,Raleigh,NC 27699-1636 W
12.Well construction method: a. ( 4,4 FI 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 (d
FOR WATER SUPPLY WELLS ONLY: • 24d.I?or Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA �f
9 ° Permit Program,1611 MSC,Raleigh,NC 2769 -1611
13a.Yield(gpm) Method of test: C'/ 6.1.I .
70% hth �/ Date Site Visited: /- 3 1 '
. 13b.Disinfection type: Amount: ( OZ Site Visited By: vp . .
i9
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
Price: '