GW1--04338_Well Construction - GW1_20240722

;TrT+L3. CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well Contractor Information:22
��`t �T� . za 04.WATER ZONES:+
Well Contractor Name FROM TO DESCRIPTION
3� A 171fr. ax ft / c) +Z.)
go IL qfrrc '
NC Well Contactor Certification Number 15.OUTKR CG 1!io&ulti c..6d went OR LINER a'
llcable
Yadkin Well Company, Inc. FROM TOASIIV DIAME IMCKNESS MATERIAL
it in.
Company Name 16.IIIIVER CASIIVG OR'TOBING ieatheimal closea46
MATERIAL fri
2.Well Construction Permit#:23-0fi L1!D H G O000C, � � � � �
FROM TO DIAME:CER THICKNESS
List all applicable well construction permits(le UIC,County,State,Yarimue,etc.) �' ,S q
3.Well Use(check well use): ft fL in
Water Supply Well: FROM TO DIAMETER. SLOT SIZE THICKNESS MATE AL
❑Agricultural ❑Municipal/Public ft. h/
❑Geothermal(heating/Cooling Supply) ❑Residential Water Supply(single) ft ft bL
❑Industrial/Commercial ❑RReesidential Water Supply(shared) 18 GROUP
❑hri ation M4lls>100,000 GPD FROM TO MATMAI, EMPLACEII MT METHOD&AMOUNT
Non-Water Supply Well ft ` r�
❑Monitoring ❑Recovery ft. ft.
Injection Well:
fr. ft.
❑Aquifer•Recharge .❑GtroundwaterRemediation 19.SAND/GRAVEL PACK a'livable•:
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACENUMMETHOD
❑Aquifer Test ❑Stormwater Drainage f .}.�
❑Experimental Technology ❑Subsidence Control fr. ft
❑Geothennal(Closed Loop) ❑Tracer 20.DRILLIIHGLOG attachadditlunal sheets iinecess
FROM TO DESCRIPTION(color,hardness soil/rock a size,etc
❑Geothermal(Heating/Coolin Retum) ❑Other explaiauader#21Remarks fr. ft. �
Date Well Started - - ft. 30
4.Date Wells)Completed: �- Well pmA&V,g9', 3 U ' . - & S' ,,
51.Well Location: ,Phone,#: i 2S f f� 1102 f� ,,,1 ,e
.�.� cs�� L;�e.-�►-��-i ,kci� Quc-1.i r c y ft. ft.
r i/)lEv`
Facility/ wne ame Facility ID#(if applicable) fr fr' 4'
n t 1
Physical Address,City,and Zip ft. ft An
OQ7�41 DRY-
County + Parcel Identification No.(PIN) 7 ` rV
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22•Certification: r
e:-0-1s' N 74, S9 �0V 1 - 2V �.
6.Is(are)the well(s): Permanent or ❑Temporary SignaturOZCtif�i ��,
ed Well Contrator Date
�� By signing ihisform,I hereby cerofy chat the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or B�Vo 15A NCAC 01C.0100 or 15A NCAC 01C.0100 Well Construction Standards and dint a copy
If this is a repair,fill out known well construction information and explain the native of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back ofthisform. 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-l�s 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: 1402 (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: v ( ) Information Processing Unit,lbl.7 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" f-0
11.Borehole diameter: (in.)glt C 2 2 7, 24b.For Injection Wells:Copy to DWR Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: &T ! r•-.!-g 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
FOR WATER SUPPLY WELLS ONLY: 14 24d.For Water Wells Producing over 100,000 GPD:Copy to DWR CCPCUA ,
'�� Z 13 V Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm)_ � _ Method of test: if '0
70% hth Date Site Visited:
13b.Disinfection type: Amount: �� OZ Site Visited By:
a.
Form GW-1 North Carolina Department of Environmental QualityWDiLvisiioln of Water R sow ccs Revised 6-6-2018
Price: t�