GW1--03228_Well Construction - GW1_20240528

/WE ,L CONSTRUCTION RECORD (GW-1) For Internal Use Only: I
1.W/ell Contractor Information:
/ i,.L�i/ Mt/S .-1.{T[_LJJ1( FROM TO DESCRIPT.ON
We Contractor Name
\J ft ft
NC Well Contractor Certification Number '.IV 01TIXR C.fiSING`(funmulti="ea`sed:we ls7':OR'LINF.R(if ap"liciti}`ef.;:,;.-
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in. Q
Company Name
!� �.16Il�TNER':GAsrNG:OR:TIIBING(j;ei�tliemaTelnied=loop)
2.Well Construction Permit#: 0 t 9 7 j - Z ci 2-T FROM TO DIAMETER THICKNESS MATERIAL (�
in. i' p
List all applicable well construction permits(i.e. , ft..e.UIC,County,State, Variance,etc.) 4- ' C jr ft l t yli"I ,o F,Z' Pu�/,
3.Well Use(check well use): ft ft in
Water Supply Well: a F7<SCRLEI;
pp Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural ❑M cipal/Public ft ft in.
DGeothermal(Heating/Cooling Supply) 6Resldential Water Supply(single) ft ft. in.
❑Industrial/Commercial OResidential Water Supply(shared) i'1g'GRODT:,'.... .
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 3,Z ft -ah Cl.\iPS ,9rc.,Vt-}y / 13c,65
❑Monitoring ['Recovery ft. ft.
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation
j'19.,SANDIGRAV>;:r'EACriif appliailile) 'a:.'.
❑Aquifer Storage and Recovery ❑SalinityBarrier FROM TO MATERIAL EMPLACEMENT METHOD - •
❑Aquifer Test ❑Stormwater Drainage ft ft.
DExperimental Technology ❑Subsidence Control ft. ft
DGeothermal(Closed Loop) ❑Tracer '20.DRILLINGIOG(atttrch iddititiiial`sheetiif:rieCei aiy)': :'C<:`l.
❑Geothermal(Heating/Cooling Re .), ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,so3llrock type,grain size,etc.)
Date Well Started 9 1.0k' 0 ft 4(0 ft 11 ` J
4.Date Well(s)Completed: y'7. `a-'\ Well ID# �' C tft 7Oii ft. 5G 4- L 4 T t leCk'\ °Vb '\Phone#:,�C- Fsi 3 -23cc. ft ?irk ft MVI y�)4 grDir }C
5a. ell Location: +� /
c . i' ft. ft. - ..
Facility/Owner Name �� Fac (rfapplica le) ft. ft
�y c{wr��ilit'� vz� �� ,{p`
/'L( 14K'�f.�i.r'�i h,,� •W v+✓,I��j ft. ft. IYil11 1 5 1�24
Physical Address,City,and Zip ry ft ft.
41 t.215T2EIWAVItR,.. ::..',".:.i;....' ,r.::. . .
County Panel Identification No.(PIN) SO I.-?0 2_ 61 /'- t. A
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5b.Latitude and longitude in deb ees/minutes/seconds or decimal degrees:
(if well field,one 1at/long is sufficient) 22.Certification:
1 C,, L51713 N ' Ci 4.,s---3 ,g,?.o w (
6.Is are the well(s): t�ermanent or ❑Temporary Signature of Gutifi Well Contractor Date'
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or It041 15A NCAC 02C.0100 or 15A 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. C
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: 24.SUBMITTAL INSTRUCTIONS
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9 9.Total well depth below land surface: f-) (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3 r)200'and 2@100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: b U (ft.) Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617 .1="
If water level is above casing,use"+"
24b.For Injection'Wells: Copy to DWR,Underground Injection Control(IUC) ru
11.Borehole diameter: (in.)Blt Off: �SYJ 1^ Program,1636 MSC,Raleigh,NC 27699-1636 01
e
12.Well construction method: l� � �\ 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the 7-0
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed S
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA -+�
r R Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) ! Method of test: n,, „C 4t h e., b.i,a..,a,._
° Date Site Visited: .3-/}'-2 y ,,,j s IA .y
13b.Disinfection type: 70% hth Amount: `�) OZ Site Visited By: b 3-z3
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018