GW1--04303_Well Construction - GW1_20240722

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10,41
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
-3--CIACI V I!eV 1a4'i WA'IK$'Y,ONES`.i:t: '.;
WellConhactorN a FROM TO DESCRIPTION M
aS7�_A „d f_,, . '/23 it savnSari+Ree�. 1 /4.1-1Z543cjps,
NC Well Contractor Certification Number '15rOUTERVASINGYfor`mnlh ed:wensill0RI.I�TEI s(i�.."h'c riS.::..:ft
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MCTserer,
ft. ft in -CA
Name J
S."
'3,.16�'INLVEIi:GASING�OR�2T7BING:(g�otliermaTcla`i�d'��p)•'
2.Well Construction Permit#: yj, FROM TO • DIAMETER THICKNESS MATERIALAT` Q
List aII applicable well construction permits(t a 1lIC,County State,Variance,etc.) *1 tt 39 ft /r/ys•1m (AR-?I /3t (1
3.Well Use(check well use): ft. / ft V 'n ✓Y ('1�7
Water Supply Well: FROM O .. DIAMETER SLOT SIZE THICKNESS MATERIAL `
❑Agricultural ❑Municipal/Public ft, ft in.
OGeothermal(Heating/Cooling Supply) residential Water Supply(single) ft ft in. y
❑lndustrial/Commercial ❑Residenlial Water Supply(shared) :18?GHOiST.'. "" . ``
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOIINT`
Non-Water Supply Well: d ft' [!/• ft. 6t r/-Cily,J istlet
OMonitoring ❑Recovery gi /ft 'ft ,No+,it re g u4^
Injection Well: v11 `-
t. ft .�
❑Aquifer Recharge ❑Groundv attx Re mediation ' r _ .
❑Aquifer Storage and Recovery ❑Salinity Barrier 4� / TO
(MMATFI ALe), EMPLACEMENT METHOD ' (11
[Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology 0 Subsidence Control ft. ft
❑Geothermal(Closed ❑Tracer '••20iDB Uli1GLOG attaci..i. ition;Isheetiifrieceli "
Loop) ( ors). ;.1c7>
FROM❑Geothemial(Heating/Cooling Return) DOther(explain under#21 Remarks) TO DESCRIPTION(color,hardness,soil/rock type grain size,etc.)
Date Well Started lr.1r'-?U /� ^ ® ft. /4 -ft SO;1
4.Date Well(s)Completed:4•Ab"gD1 Well1D# Ma.- ail x /9 ft. 4/'/.'ft me/ got /t 0
5a.Well Location: Phone#:336- LAO 7173 ft. ft �/ .7_.
�
r^ ft. ft ,. �` f
)tL� Jam{-}- 6rt,,,V 336• of-6731 f �1
Facility/Owner Name Facility ID#(if applicable)
NC - IS 5pArf6. Isle a 673 ft. ft. JUL 2 2 2024
Physical Address,City,and Zili ft. ft
ilAv,r,-A,Tr,; e ? ;
;.2i#3i1vt+�3alrs_.:;:::':.:;•�• :�;. _: -� �.�Lr�
A I I����r >�,:.:�3��;
County ' Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
. 3()`' 31/ Sin N S1v 3 i e21i W /7c71' to.›-/2• 0.40
6.Is(are)the well(s):lermanent or ❑Temporary S' oEe of cdwell ontractor 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: [Wes or o 1SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out brown well construction information an explain the nature of the of this record has been provided to the well owner.
repair under 1121 remarks section or on the back of this farm.
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 er needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: 1/ �'� (ft') Submit this GW-1 within 30 days of well completion per the followingi
For multiple wells list all depths ifdifferent(example-3©200'and 2®100)
10.Static water level below top of casing: 7s'• (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing use"+""
11.Borehole diameter: 6 (in.)Bit Off: 4,•/01 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Ai I TO 'tit y 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 'I-
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA 2
13a.Yield ° Permit Program,1611 MSC,Raleigh,NC 27699-1611 4
L
(gpm) /,- Method of test: JS 0.1 Date Site Visited: - /Z- 1/ f
. 13b.Disinfection type: 70 0�o hth Amount: �S• OZ Site Visited By: /1/1 C z,q
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018 ' '
Price: