GW1--03585_Well Construction - GW1_20240613

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;ivf+,LL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
6
G��s ���� ,4:WATE$'ZONES`%ta..
_______________
FROM! TO DESCRIPTION -1
Well Contractor Name
2 rl O ft. 230 ft. Sow.
ILA�0`r� `"i o Ilk
w10- A j ft. i. 10 ft- ifiL - JL•s#,. C
NC Well Contractor Certification Number
:15'OUT'ER•CASIN" (for`.mul4=ca'sed"vre11 :OR13NERi('ifap licatilej.:
Yadkin Well Company, Inc. FROM TO D ER THI/K rESS MATE�rrAT _
t. ft. in. // /
Company Name Huy
"1 u y 1 .7�i .6` ('AS G:ORa: B G(geiittiazmal'dared-loop)' .:.f -
2.Well Constriction Permit#: J� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) ,t, 1 ft. 1 (3 ft. (//s.1 2 J 1 in- `dr 21 "ti(•/
3.Well Use(check well use): ft. ft in. �/ ,
z f 7::$.CREi
Water Supply Well: FROM TO D SLOT SIZE THl SS MAT
CL
❑Agricultural ❑MunicipallPtiblic in.
❑Geothermal(Heating/Cooling Supply) >iesidential Water Supply(single) /
ft 7ft.
ft in. l
❑Industrial/Commercial ❑Residential Water Supply(shared) -Y8'7GR-0UTi': _
❑lirigalion ❑Wells>100,000 GPD FROM TO MATERIAL I EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: C) ft 0 ft. r C .'p' 6ro.`;#'/►I bye I
❑Monitoring ❑Recovery ft. ft
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation _
❑A uifer Storage and Recovery ❑Salmi Barrier t`]9.SAND/611'4V YACK'(MATE$Aai ..E
q g tY FROM T MATEy�AL EMPLA METHOD
❑Aquifer Test DStormwater Drainage ft. ft MAT
(f
❑Experimental Technology ❑Subsidence Control ft. ' ft.
❑Geothermal(Closed Loop) ❑Tracer '201DRIf,ISNGIAG(attic:li idditionaril eets''ifnecesiary)::;,
FROM TO DESCRIPTION(solar,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
Date Well Started 6. 2 6j ^pry t 0 ft.- �0 a ft t)� d
4.Date Well(s)Completed:'S'2 if Well ID#AA& G- / O { haft. `A ft I, iva. roe 6Y�
5a.Well Location: Phone#:coo .-V u 7 ei. 170`7 346 ft. liS t7 ft Wk. V��ik d"
//✓
Oki'
11A4 t7 Od ft. 602 ft fir _ OC a
Facility/Owo rName a Facility ID#(if applicable) ft ft' 1�_ _
Lv r z 1 4.1. G+ itl''vdJ„lt� Wv� ft ft. `-; r.-'`.P 4..i,`r
Physical Address,City,and Zip -J F ft ft . i
Yd fir LiU�C'� :.].1'}l2F.M�RYCR,.::` L 17,._
County Parcel Identification No.(PIN)( friOf� £� ' r r '., ' •�
IE.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: fit'Cd St1ts -Pb
(if well field,one lat/long is sufficient) 22.Certifiicati _,_
3131 I1)' is" N 8) ..i e 6 .r/ W Wy �! (,i�:_-
6. C- .f ZY
Is(are)the well(s): ' ermanent or OTemporary
Signature of`Certifeed,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 ISNo 15A NCAC 02C.0100 or ISA 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 l GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: i24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Ga 1 (ft.) Submit this GW-1 within 30 days of well completionper the following:
For multiple wells list all depths if different(example-3(4200'and 2©100) y p
10° 24a. For All Wells: Original forms to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing use"+"
11.Borehole diameter: C (in.)Bit Off:•sqlj, - 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: et' r r ea 4 G r 7 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the N
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLSONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) J'�J Method of test: J-1 , ,k i Permit Program,1611 MSC,Raleigh,NC 27699-1611
70% hth Date Site Visited: LI - ) - •2 ii
13b.Disinfection type: Amount: 16 OZ Site Visited By: A145
Form GW-1 North Carolina De artment of Environmental Quality-Division of Water Resources Revised 6-6-2018
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