GW1--04316_Well Construction - GW1_20240722

-vVE%, CCYNS-. k-'Tj'C T.1I-ON 1T<E'C C)RD ('GVV-11 For internal Use Only:
1
1.Well Contractor?n?ornn 'on:
t 14.WATER ZONES
FROM TO DESCRIPTION
We!)Ccitraetor Nameft ft
NC Xsll Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LINER if a licahle
'W YADKINELL COMPANY,INC. FROM TO DIAMETER THICICNES5 MATERIAL
Codpa ,v Name i1S'l�7f t✓�s+V n�c/ W `�ti( y( �.
�(-R 16.INNER CA OR TUBING( eothermal closed-loo )
2.'We;'Construction Permit#: S �d OI I_� 7 PROM TO DIAh[ETER TffiCfINESS f•LITERL4L
Litt ',rpplicable well construction pumits(i.e.UIC,County,State,Yarionce,etc.) k. ft. in.
3 We!Use(check well use): ft'
;Water Supply Well: 17.SCREEN
FROat TO DIAMETER SLOT SIZE T87CTUYESS MATERIAL
OAg cultural OMunicipal/Public ft. k, in.
OG--nicrna!(Heating/Cooling Supply) OResidential Water Supply(single) f — --
1 01ndn.:rW/Conmerciaz ❑Residential Water Supply(shared)
18.GROUT
Gurige'lLn OWells> 100,000 GPD FROM To MATERIAL I EMPLACE E METHOD&AMO NT
N.on--Atater�jupplyWell: ft. tL
OMonitoring ORecovery ft. ft,
Injection Well: ft. k.
oAquiferRcchargc ❑GroundwaterRcmedialion
19.SANDIGRAVEL PACK(if a iicahle
❑Ao�rfer Storage and Recovery OSalinity Barrier FROM To MATERIAL EMPLACEMENTMETHOD
OAg,iifer Test ❑Stormwater Drainage ft. ft.
1 DEx-^erimental Tecluiology OSubsidence Control ft.
I
OGF':thermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soi
OGVroek e, aio sae,tic.
e.thcrrral(Heating/Cooling Retum) :]Other(explain under#21 Remarks)
k, ``7/'t k.
v.Dztc tiV ell(s)Co In pleted: Well ID#
WwV rG1 .xyn -�-. — --i
r'r Phone #
IILoratioa- a(c 1ci`Z. �� ft. ft.
ft. n.
i3ur.�he rr
r'a//c;,, }^!O•vet Name Fac lily IDO(i^^fle) ft. ft.
_`f'� !�t�n� �t.�w.� (Z� �.�1t�� �'•w tM ft. k. ➢refr::r..rai�'i; ?►-�ranr.;•-��� i
PLys.cr Address,City,and Zip 5 ft. ft.
Zl.REMAR
`i� � KS BORES 't
Co: = Parcel IdenEBcaaonNo.(PIN) (�) DEPTH (`T�tJ \, G•.l till ( t✓ �tf }
5b.'..atitudc and longitude in degrees/minutes/seconds or decimal degrees: LOOPS PER BORE ( , DIA OF LOOPS(/
field,ooclat/longissuSicient) 22.Certification: SDR OF LOOPS ( () ( )
6.1r are) the well(s): OPermanent or OTemporary Signature ACerlt2fified Well ntract Date
By signing this form,I hereby certify that the welt(s)was(were)constricted in accordance with
7.i^ this a repair to an existing well: OYcs or allo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction S'tondards and that a copy
Jffri. 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.
rep under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
k. or Geoprobe/DPT or Closed-Loop G'Mtbermal Wells baying the same You may use the back of this page to provide additional well construction info
Jn•:action,only 1 GW_is peeded. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box; You may also attach additional pages if rccessary.
r d. (G (� 24•SUBMITTAL INSTRUCTIONS
Total well depth below land surface: /Q� (ft.)
Fa, multiple wells list all depths fdiifferent(esample-3@200'and2©1000 Submit this GW-1 within 30 days of well completion per the following:
10.:.tatic water level below top of casing:_ 00 (ft) 242. For All Wells: Original form to Division of Water Resources (DWR),
^r level is above casing,use "+^ Information Processing Unit 1617 MSC,Raleigh,111C 27699-1617
11. ;orchn'.e diameter: CG (in) Bit Off: �' 24b.For Injection Wells: Copy to DWR,Undergromc injection Control (IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.'l'c1J co,;truction lflethad: AIR ROTARY ,.
24c.For-Water Su I and Open-Loop Geothermal Return Wells:Copy to the
ft.s.;.,.�_r.:orery,cable,direct push,etc.) county environmental health department of the county where installed
FO'I lYATER SUPPT�W);LLS ONLY:
f��Jl t 24d.For Water Wells producing over 100 000 GPD Copy to DWR,CCPCUA
13a Yield m r Permit Program,IN 1 MSC,RaJelgh,NC 27699-16)1
(gp ) Method of test: / n.1�ctxSref r K'S V
13:.Disinfection type: 70%HTH Amount: ,../ OZ DATE SITE VISITED: Z.
PS.. .^_P- VISITED BY: P:W
Fc: ;OW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 6-6-2018