GW1--03244_Well Construction - GW1_20240528

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. WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information:
A,� > .�
/k i r G� ✓� tt 14 WA,TE$'ZONES'4s ti= �►�
(, FROM TO DESCRIPTION
Well Contractor Name ft. ft
5 34? —A ft ft
NC Well Contractor Certification Number ;:15?OIITEI;':CASING(foimnfi"caie id'well0:012:LINER'(if,sp licililef,; 1�•
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS J MATERIAL •PI,
ft. ft. in.
Company Name
\_ ss;16'IIQNERC iSINGOR:i uBING ercaliiFfiiit eloiirT-loop)' . CO
2.Well Construction Permit#: 17 3 5.) 2S FROM TO . DIAMEI'Rx THICKNESS MATERIAL
List all applicable well construction permits 0.e.UIC,County,State,Variance,etc) ft. ft uL
ft. ft. h.
3.Well Use(check well use): ".,......
Water Supply Well: FROM TO DIAMETER :.LOT SIZE THICKNESS MATERIAL
❑,a gncultural ❑Municipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft in.
❑Industrial/Commercial .esidential Water Supply(shared) 18 GROUT ; - — p
❑ln-igation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD 6rAMOUNT .efi'
Non-Water Supply Well: ft. ft. — d .
41.
❑Monitoring ❑Recovery ft. ft •S.
Injection Well: ft ft t r
❑Aquifer Recharge ❑Groundwater Remediation i�1 y. ..< S`. •0 rt
1'19.SAND/GRA ..EirP,ACW(if it plia li)t VI
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft .
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer '20:DILECIINGIOG(attach iddiuouaiilieeti ifneciiii y):''''.. •.
FROM TO DESCRIPTION(color,hardness,solllroek type?grain sire,etc)
❑Geothermal(Heating/Cooling Return) El Other(explain under#21 Remarks) lift ft' '
Date Well Started Le--z--Z /� / f( O9 2306 1v f �)l`�`f �O la�� y
4.Date Well(s)Completed: 4-(�).4 Well ID# A — 1 D ft. ft
5a.Well Location: Phone#: b?g- 3g)- 6,6 ft. ft
t ft, it.
A3L7 4r�Z 4161b C II/LA�L,. i be1's., =Sr.l I ar.i t. ? `,
Facility/Owner Narne Facility lD#(if applicable) ft ft 1 1 ro — �' es,'
C J �y^,. r ,}� ft ft Os U s f
6 . 7 .Sv.,•1 Cif LAMiy 1 t7 rt ft. 1301)/1141" ft. ft 2 210
% 1 0 p s,
Physical Address,City,and p e2g * f GsL-
f,sk Al 14.0 r_,. 3-t,,,„e. l6,- v 3--g! l I �j
County Parcel Identification No.(PIN) ;'et-- AA L— 'ia 1 rtec rii
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: ~
3 L! 'I 7;i5'1.1 N aii 7 0 3 6 0 w aptita) C. 4(...,eldv..c
6.Is(are)the well(s):X'ermanent or ❑Temporary
Signature of Certified 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: t es or l'JNo Ut'i'i' CSUAL1 ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out brown well construct i information and explain the nature of the of this record has been provided to the welt owner. (�-Jy
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details: V
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page A provide additional well construction info (to
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).Yot.may also attach additional pages if necessary.
drilled: N 24.SUBMITTAL INSTRUCTIONS
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9-Total well depth below land surface: O�7 (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2©100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-161'l
If water level is above casing,use"+" +
11.Borehole diameter: (.s (in.)B it Off: ' 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC) Wa
►O J[ Program,1636 MSC,Raleigh,NC 2'7699-1636
12.Well construction method: 4 ' r r,z'> t 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
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 374 Method of test: i f K ,,tr.
° Date Site Visited: 3 I Z— 2`f
13b.Disinfection type: 70�0 Nth Amount: !2 OZ' Site Visited By: A/6
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Form GW-1!(► North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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