GW1--03583_Well Construction - GW1_20240613

WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only: CP
1.Well Contractor Information: 0
V` IViCIt-.I , )/IV 1173 4 WATEgZONFS�a0.� " • , •
Well Contractor me FROM TO DES
CRIPTION
�571� —/ag c �c
�09k SvJa '/�..k_ Fr
ft. it
NC Well Contractor Certification Number '
15.'OIITRR"CASIN.G'(ESiiulli"c`ised:weIIS DRIMR;(iriirti lil
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
/ ral''A•TEICCASINGOR3 IBING:reithermaPdmed=1881i _ :_ i. . , . •.
2.Well Construction Permit#: 0 FROM , TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 4-, / ft /a.`�ft. 4,/?,�"in- C'` .e a i '� t, -
3.Well Use(check well use): J ft °�� ft. in. �![/^` /►'
Water Supply Well: i'�-.1.7:;Cttt, iAliWifi4F �'.6'.•:ti
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) XResidential Water Supply(single)
ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) i'1ti'�Giitl'OT .
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 6 ft y' ft. /.poi ,p,`v�
❑Monitoring ❑Recovery 4/ ft 01/ ft m ry y Jam" AO
Injection Well: ft. ft ` /alio
DAquifer Recharge ❑Groundwater Remediation
DAquifer Storage ❑Salim Busier 1-i19.SAND/' '"-.Y.>,tiY.ACICr(;f cabie). -:'.`•' ":.. ;":. - • .
q rng Recovery tY FROM TO MATERIAL EMPLACEMENT METHOD _
DAquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control fL ft.
❑Geothemlal(Closed Loop) ❑Tracer ':20.DRILtiNGI:OG(stticb dditlonal'iheeti tf necessary) ... ..
❑Geothermal(Heating/Cooling Return) El Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Date Well Started 5--f3 'I ^ / ,1 o. ft- 175-1 4a,,1
4.Date Wells)Completed: aC) Well ID# � /7V �� S ft Taw it, -7,a/ F,�O�''7r
5a.Well Location: Phone#:330.. 43r—/�7C, Sa—d ft. g�v ft to/_( ./ /�/_. /l
ft. ft cJl�v���v// b L rl A
R��« Scflh(b . ""
Facility/Owner Name Facility ID#(if applicable) ft ff \4.�`.I L i i, /F 0 - �
v �
Lot 27 Black6e.i/ ,�i,' 147s ft ft
Physical Address,City,and Zip ft. m J U N 1 S 2024
1 '.i2ttRFMARTrR ../.r,..�-:1.
County Parcel Identification No.(PIN) DI;Co li•w
0.0
5b.Latitude and Iongitude in degrees/minutes/seconds or decimal degrees: C>
(if well field,one Int/long is sufficient) 22.Certification:
36, II .'; i N 81, X' s; W
6.Is(are)the well(s): Xlermanent or ❑Temporary Si o ed....A j At j&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 A. ISA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction hrformation 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 W 1 is needed. Indicate TOTAL NUMBER of wells (add Over'in Remarks Box).You may also attach additional pages if necessary.
`filled: I 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 8 a 0 ft ra
For multiple wells li tall depths ffdifferent(example-3®200'and 2Q100 Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 3(,4Pr 51949(ft) 24a- For AIl Wells: Original form to Division of Water Resources (DWR),
Iffwate level is above casing,use"+" / h Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in,)Bit Off: .I40 24b.For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: a•' /a 7 /' 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
i(i/ Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 5- Method of test: I
70% hth ,,��. Date Site Visited:
13b.Disinfection type: Amount: /v.]. oz Site Visited By:
Ferny GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
Price: