GW1--03226_Well Construction - GW1_20240528

WE-XL CONSTRUCTION RECORD (GW-11 For Internal Use Only: 'E
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1.Well Contractor nformation: r
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Well Contractor Name FROM TO DESCRIPTION
3�36A ,2.3� a.w�� au
4.
NC Well Contractor Certification Number 7'tti � 2
r1i'OIITER'.C'AS.11,10 bicmnlii ced-weIIII:ORITIVFR'(iririi ref::
Yadkin Well Company, Inc. FROM DIAMETER ' THICKNESS MATERIAL
ft. 'in.
Company Name
g.:1-6xlPINERC.SING.OR TUs .G: dtliezmaf cldi8ii-d$bp) .:;i •
2.Well Construction Permit#: ©`..O I Ct'7 2p 3-, Y- FROM TO . DIAMETER THICKNESS MATERIAL v
List all applicable well construction permits(i.e.U/C.Cowiry,State,Variance.eta) + I ft' 3 1 ft' 6 V m' spit-a 1 PVC
3.Well Use(check well use): ft ft in
Water Supply Well: r.17: CR1 ;:..,:."::"•:::..:::.:i:::. :';:.:.::,:,••, ,:•;..: . .
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Mundentia Wale fti /
❑Geothermal(Heating/Cooling Supply) !lddential Water Supply(single) t/ft// /
❑Industrial/Commercial ❑Residential Water Supply(shared) 'igr au< . :.._: :i ..:..:.,. :. .;' .-:: .
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 21/ ft &A 4 iia (Air, 6,-4,,,'/,, /0
❑Monitoring ❑Recovery ft. ft
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation
1119.
'❑Aquifer Storage and Recovery ❑SalinityBamer p � o0 e)i TERI+iL EMPLACIMENT METHOD -
[Aquifer Test ❑Stormwater Drainage
❑Experimental Technology OSubsidence Control ft. ft f /
❑Geothermal(Closed Loop) ❑Tracer 20:321R1f7 VGZOG(attitel additionil'slieetiifnecrssaiy):': " ? ..i ... ...
FROM ElGeothe>mal(Heating/Cooling Return) DOther(explain under#21 Remarks) To DESCRIPTION(color,hardness soil/rock type,grain sire etc.)
Date Well Started ...1"- a- IN © it 3 ft .S,,'/ /
4.Date Well(s)Completed: ,f--15'�11 Well ID#A A&`(S� g fr. ,2,f- f Wu N.,i7' Ibth� &fAn ,,'v. �a,.ehe.4..„
5a.Well Location: Phone#:.33 4 C- OI YO ,- ft. f' /o ft A� &'#A }L
f14 kV
Yvty a5sv�r .240 ft, a3oit ft' H Axel ora.t,'fit. 5-
Facility/Owner Name Facility ID#(if applicable)) ft
Coll 01.E i'w yr O a. Y2-1 k), '� ,�,J1 ft. ft. . .__.t. .., #
Physical Address,City,and Zip ft. ft. MAY 1 S 2024 E-
Yet (Ll N :2111ZIr •�litS :- ,y , i.l gd 7 � .T'e"; (-1)
County Parcel Identification No.(PIN) i . r_
Sb.Latitude and longitude in degrees/minuttes/seconds or decimal degrees: V ,
(dwell field,one 1st/long is sufficient) 22.Certification:
--#41416----.e,-&-.----- ,r, x..2 di
6.Is(are)the well(s): i$parmanent or OTemporary
Signature of Certified Well contractor Date
By signing thi:form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or 19Se ISA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a copy
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 G7-1 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
nd
9.Total depth below land surface: 3 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple
w wells list all depths if different(example-3©200'and 2Q1000
'0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing use
e""+"
11.Borehole diameter: }e' (in.)Bit Off: . U 4 p 24b.For Injection Wells: Copy to DWR,Underground Injection Control add)n- /1� Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Ayr C.'Lfr y 1 4 d- 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
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Method of test: f/� L(S 1' Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
13a.Yield(gpm) I-% q'i vc .,a •-.11 c ueaAty
o Date Site Visited: -r' 2 /'
13b.Disinfection type: 7O�o hth Amount: 3 2.. OZ (125
aSite Visited By: IS
Form GW-1 North CarolinaDepartment of Environmental Quality-Division of Water Resources Revised 6-6-2018