GW1--04297_Well Construction - GW1_20240722

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
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ti +10 se./ v_ CAAC A t'.14i WATEB•ZONES;': 2 >:
Well Contractor Name FROM TO DESCRIPTION
/ i3- ft. (G b ft
. U .) L' A P3 e ft .23? ft- 0
NC Well Contractor Certification Number 1-5`3IITYR:C.SING'(fo liiii1 i;cased'we114:0RLINER.:(ifap li clef;:
Yadkin Well Company, Inc. FROM ' TO DIAMETER THICKNESS MATERIAL ��
ft. fL /a/ ".k. ".'
Company Name
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`16`NNEI CASING OR';1'llBING(geiitlielimal`cldiedloop)' 0
2.Well Construction Permit#: 3,3 U `7 q 7 ,7 FROM TO - DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(.e.U1C,Comity,State, Variance,etc) + ' f[. 6_r ft j i/� in �p�� / ��/i
3.Well Use(check well use): ft. ft V l i� �!/ 1 le _
Water Supply Well: RFFI�, 1
71
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public rt. ft in. ^y
•
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft f in. / t `y
❑Industriallm Comercial ❑Residential Water Supply(shared) 18y6 rr// i
❑it igation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT Non-Water Supply Well: ® ft' d/ ft L, ►,►7,fe. C/,; G,',v,JT /y i,
❑Mot,itoring ❑Recovery ft. ft 7' iv
Injection Well: 1
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
i`.19.SAND/GRAVEti:P.AACkq f'irlres1i1e) _ .. . .... . ..
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ❑Stormwater Drainage f ft
❑
❑Expeaimental Technology ❑Subsidence Control ft. t//''''' /
❑Geothermal(Closed Loop) ❑Tracer `'20:DRIIL.INGI OG(attach idditiona`sheetiifnecesiary):'''.'...'r';.. . ...
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/reek type,grain size,etc)
Date Well Started C.r!a 24 /) /i) �t (i fr- j--Si ft .s®,/
4.Date Well(s)Completed: e I�" H Well ID#1 C IJ� /0/ •
..� it 90 f' Jo- -t� 6 i,,y,'AL,/d rJ;o„t �t�j,� /�
5a.Well Location: Phone#:�.3 a�_S 9.S-c991 90 ft. Z6s Z ft 4 .,
Es 1 ft. ft , .,. � - ! ` t.-.A
r;C P!'JrTor ft. t.... .. ,w. `l/
Facility/Owner Name f, Facility ID#(if applicable)
e
.mil CVJ A L6."'I '/ p r t C l Ls,vj Sete.o.r ft. ft - JUL2024
Physical Address,City,and Zip / ft. ft I fefO r i
I�1 S•IC: _2v4 I ' 21:�RF,M�R S:. _ ..�, ;'�.•:.�
County Parcel Identification No.(PIN) Mild p`tor i �T1`� C
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: �/3 ,�) 7 -1 N ! t 2S 70 _W �Z / Fj -2
6.Is(are)the well(s): XI'ermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby cert fy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or )(No 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.
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 i/s needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: n 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: c(f / (ft.)
For multiple wells list all depths if different(example-3Q200'and 2©100) 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: 0 (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use•'+"
11.Borehole diameter: 6 (in.)Blt Off: CI 0g23"1
24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC) 'N
{{�t Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: (�i. r •l- Mv:,t -1.)'1-er r le 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
4
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) Method •
of test: r`/Q� air 7 �'
70% hth !lr�n oZ Date Site Visited: b - ,2 - ._) �
13b.Disinfection type: Amount: O! Site Visited By: V (' 4-. ..y CP)
22 ' G
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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