GW1--02311_Well Construction - GW1_20240410

a WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: E
ATA +4"4R (0tiY✓1 C`,1%F:.WA11+d3�ZON�SKF,, 7:3y::i5i!ra ';:-L'a "'i.-. . 'Y.e..s.`{f—,:.;1:i{ ^.:i':.v:, d •
Well Contractor Name FROM TO DESCRIPTION
/®
' p of lot ft. 2'l.7_ ft....... i
NC Well Contractor Certification Number '1 ftG'7 ft�
t15:OUTER'CASING'(fo m lti eesed7wells)ORLI ER"(if:iip lic'able) ;<?:.o
Yadkin Well Company, Inc. FROM TI-- DIAMETER ; THICKNESS MATERIALCoft
0
Company Name • 1
y • 1161INNERIGASING:ORUDBING(ge'otliermal closed=To'up)c:.'''-'f
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(I.a,UIC,County,State,Variance,etc.) 4 9 ft in ft. WY in. ®d'ges,//, //. [L
3.Well Use(check well use): ft ft In ca r e✓r
e.
Water Supply Well: 7 tS: S'_: --, . :-< ____ -•--------___•— __ _ _— _---
FROM TO DIAMETER SLOT Cr7R THICKNESS- MATERIAL
DAgricultural ❑MunicipaUPublic ft , ft. i in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft X its°' • 7
❑IndustrialCommercial ❑Residential Water Supply(shared)
❑Irrigation ❑Wells>100,000GPD FROM . TO MATERIAL EMPLACEMENTMETHOD&AMODNT
Non-Water Supply Well: ft ft
0 �°f Qv���4. arr_s 6,,tV;4y 1 111'6 J.
:Monitoring DRecovery ft. ft.
Injection Well: ft. ft
- -
❑Aquifer Recharge ❑Groundwater Remediation
i'`194.5'/IND/GEAVEfiVACECifagplicable)L_=.1_- -_._---_- -.
❑Aquifer Storage and Recovery ❑Salinity Barrier PROM - TO MATERIAL EMPLACEMENT METHOD - •
DAquifer Test ❑Stormwater Drainage
ft ft yr":•
❑Experimental Technology ❑Subsidence Control t ' it. / �� V�
DGeothermál(Closed Loop) OTracer ;20c3iR1ii'INGTOG'(attiialis`dditlonii'sheetaifnecessary)2�` _ ,
❑Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,saillmek type,gnat size etc.)
Date Well Started 3--7,.a L4 A/f /f 0•. tt' •90'. ft. .�;>,°. / rill G�ir,j cfet,7
4.Date Well(s)Completed: /- Ay Well ID#P'1 f'P�—®7® L�Q ft „� ft �� ����e
Sa.Well Location: Phone#: ���® �� �N®� � , ft.- ® ft ��d � �
Facility/Ow/r Name Facility ID#(if applicable) ft ft' l• •� L,4' ., l'y'
elA p Al Z.0Avi!1i., Ail 6 1g ftft APR 102,"
Physical Address,City,and Zip
p laDRE1CMICSt4' _1rx:-- _.�151:--7-_r., -��,_.
County Parcel IdentificationNo.(PIN) Gt';rt,•"O`
. Sb.Latitude and Iongitude in degrees/minutes/seconds or decimal degrees:-' •
-
• (if well field,one lat/long is sufficient) 3� p p -
22.Certification:
3( d716®B N (' � �'�' � y �� W •
e: 3-7_ay
6.Is(are)the well(s): Permanent or ❑Temporary Signature of Certified Well Contractor Date
��yy'__ By signing this form,Thereby testify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or l'o 1SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Staindards and that a copy
If this is a repair,fdl 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. 10.
23.Site diagram or additional well details:
4.711
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-iris needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS, p)
9.Total well depth below land surface: 3 0 the following:
per completion(ft) yP Submit this GW-1 within 30 days of well
For multiple wells list all depths if-different(example-3(3a 200'and 2Q100)
1..0.Static water level below top of casing: g#® (It) 24a. For All Wells: Original form'to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: 6 (in.)Bit Off: 6 a 07,d/ 24b.For Injection Wells:Copy to DWR,Underground Injection Control(hUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: t i I'//444 ro""eR,9 r 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the 00
(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
p
13a.Yield(gpm) / Method of test: 1rI3 ail i Permit Program,1611 MSC,Raleigh,NC 27699-1611
70% hth Date Site Visited: .- ,e,6; 'a 3 . [r,
. 13b.Disinfection type: Amount: 0 OZ Site Visited By: Ail I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources _ p ed 6:.-2018