GW1--04296_Well Construction - GW1_20240722

WELL CONSTRUCTION RECORD (GW-1' For Internal Use Only:
1.Well Contractor Information: S
J .
(Am� � !$.1.4i WATERZONES '`,;'.,:, �—•
FROM TO DESCRIPTION
Well Conrctoz Name I O/) ft. 20 ft 5b♦:1 piPki
I`
({dill A Ydo ft. 1/20 ft. J51.140 ., cx
NC Well Contractor Certification Number
v ica'i:15:'O 'CASING(fo'rlmulli"ce'sad"WeIIs�`:OR'T,TNF,R<j;fap le)::_'.:.
Yadkin Well Company, Inc. FROM T n THI Ss 1 MATERIAL
t, ft in.
Company Name ,._
yC 9 CI q „I6 :G Tit
(geotlietbillitl sea:36op)" •
-
2.Well Construction Permit#: �,) 1 FROM TO . DIAMETER THICIav%SS 1�ATERTAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) + 1 ft 7! ft /�10 V y in. �2'r O/ln/
3.Well Use(check well use): ft. ft. ! in,. ( V C
Water Supply Well:
FRO TO DIAMET SLOT S ZE THICKNESS MAT
❑Agricultural ❑Municipal/Public ft f
❑Geothermal(Heating/Cooling Supply) iesidential Water Supply(single)
ft ft in.
❑Indushial/Commercial ❑Residential Water Supply(shared) Y9`GROU`r_•
❑Imgation ❑Wells>100,000 GPD FROM TO MA EMPLA METHOD&AMOUNT
Non-Water Supply Well: 0 ft. '1 j ft 15 rrj ra [� J 10 �i y
❑Monitoring ❑Recovery 4' ft. 2 ft F� V ,// W
4011
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
j 19.S 7017AVEI?3?ACle(itifir1i`c'a i :.• .. ..... .
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MA .. EMPLA MENT METHOD ' -
❑AquiferTest ❑StormwaterDrainage ft. ( ft.
❑Experimental Technology ❑Subsidence Control ft. it.
❑Geothermal(Closed Loop) ❑Tracer 20:DRI11SNGLOG(attach idditiiha.iheets if:necessaiy)
❑Geotheimal(Heating/Cooling Re ) 0 Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillroek type,grain size,etc.)
Date Well Started 1—(4—2 � ')
4.Date Well(s)Completed:/ i— Well ID#44 6 7d ft. Ii tot
5a.Well Location: Phone#:33t, t:9 - 'I 3`1t1 ft. ft , ,i J d __
Li ei n A 11 tit, 0 ft. eV ft. 7un ra, cSo .{<}
Facili /Owner Name (Pi Facilityc ID#(if applicable) (��/ yid ft a 2 fr' h, row a '�T
ki wi, ' 0(+t1,N v g 6 d / ft. ft i
Physical Address,City,and Zip ft. ft. ��'��i I� L
,r(
4\S /_6 ',:21;RRMARYtS:'.:_.:'r..'.�`•:'�s..:1
/'J si Ut 2 2 2024
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ,t,:,:;:,,.' •". :)':-''.fir',' -. Utz
(if well field,one lat/long is sufficient) 22.Certification: ''`"°.G'3
36 3 3 490 N 1, SS 7 41 w 7-112
6.Is(are)the well(s): Permanent or ❑Temporary
Signature of Certified Well Contractor Date
By signing this form,I hereby certify that tine well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ko 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 wet 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 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
9.Total well depth below land surface: 3-.a (ft.)
For multiple wells list all depths if different(example-3Q200'and 2®1007 Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: d� (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: ti (in.)Bit Off: ),Ts 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: a, / c 4-4 r'r 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the 1
(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/P r,,i
/ i Permit Program,1611 MSC,Raleigh,NC 27699-1611 1�
13a.Yield(gpm) 5 Method of test: ,t'li o 470% hth f Date Site Visited: V It-2 k
13b.Disinfection type: Amount: l3 oZ Site Visited By: Ai 4
f e/
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
Price: