GW1--04332_Well Construction - GW1_20240722

WF+>G�L CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractormation:
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W OM TO DESCRIPTION
Well Contractor Name 401.
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NC Well Contractor Certification Number :;:liJO :GilSIIVG`(foriiirilfi>'easeIl"wells'ORLYNE$;rf3f• licatde
Yadkin Well Company, Inc. FROM TW DKIER I IM
ft ft. in.
Company Named it Vt p `l !GASING:OR;TQB G:'' otliermal dosed ISo
2.Well Construction Permit#: (1SbG � 2(,2* ^ 9 O T 2 t
To DIAMETER 'rl�tS4vass %eTESftIAI.
List a0 applicable wnQ corrstrucdonpermitr rl.e.U1C,County,State,Variance,etc) �.. in. (/2 V&
3.Well Use(check well use): ft.
Water Supply Well: FROM TO D AMETER SLOT SUM TFll s MAT
❑Agricultural ❑M cipal/Public It
9n.
❑Geothermal(Heating/Cooling Supply) dential Water Supply(single) ft in.
❑Industrial/Commetraal ❑Residential Water Supply(shared)
❑lrri ation ❑Wells>100.000 GPD TO y ATE �� oD&AMOUNT
Non-Water Supply Well: ft❑Monitoring ❑Recovery ft
Injection WeV ft. fL
❑Aquifer Recharge ❑Groundwater Remediation �.,:.... .._
❑Aquifer Storage and Recovery ❑Salinity Barrier FRoM ft. To 14IA F1v1PI A METaoD
❑Aquifer Test ❑Stonnwater Drainage ft
❑Experimental Technology ❑Subsidence Control ft
❑Geothermal(Closed Loop) ❑Tracer '•20 DRI>T�2ICtI OG arirch`iaditional'sheeti riecrss
Vt,
TO DESCRU'TTON color,hardness sail/rock e, size,eta
❑Geothermal(Heating/Coolin Return) ❑Other(explain under#21 Remarks) S ft
Date Well Started - n� ^
4.Date Well(s)Completed:6, q- y Well ID#AAA-2�/ Y 2 0 f '� r-
5a Well Location: Phone#:A4 �-Yki^3X.2 t% ft ��. 1, !./d
'L,,, �--70 y._ S''Sq-S3qk p a d
Tim�v Ti-i i/�T�- r`,
Facility/Owner ame // / (� t Facility ID#(if applicable) ft ,
i4lQ ZJC-" L✓ -e ay RA N f,t�h L7f'Of/t► ft. ft ,�. a.. : V1.r
Physical Address,City,and Zip Oiv 1 qU 9-11 ft ft J U L 2 G ?U 4
County Parcel Identification No.(PIN) ifrv:' +• J J v "7'Jt i
5b.Latitude and longitude in degreeslminutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
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6.Ts(are)the well(s): ermanent or ❑Temporary
Signature of Certified Well Contractor Date
� � By signing this form,I hereby certify that the weD(s)was(were)constructed in accordance with
7.Is this a repair to an e3isting weIl: ❑Yes or V. 15ANCAC 02C.0100 or 15ANCAC 01C.0100 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 prov/ded to the well owner.
repair tinder#21 remarla section or on the back of thisform 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: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surfacer (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2 r@100D
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 775 (ft) Information Processing Unit,1.617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11,Borehole diameter: ( •)Bit Cffi.�fl.()2 2 Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 64 Y!4 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the Z
(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
r Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: A _ U
c Date Site Visited: -) -2 T v
13b.Disinfection type: 70�o hth Amount: OZ Site Visited By: D
� 6
Form GW-1 North(—Iz, .r,--- -- 'onrneatal Quality-Division of Water Resources Revised 6-6-2018
Price:_