GW1--04340_Well Construction - GW1_20240722

..Iv I,L CONSTRUCTION RECORD(9'W-11 For Internal Use Only:
1.Well Co tractor Infor ation:
Well Con NaL
ggpM TO DESCRIPTION�� ft. 541 'Lie f
1h�f 1
ft ft
NC Well Contractor Certification Number 15.`0UXJ=M` ASIIQG` ormulti sedweIIs:ORIINFR(ifa'°ltcabae
Yadkin Well Company, Inc. FROM TO DIAhMTKR THICI IMS MATERIAL
ft. ft in.
Company Name 7
c� '� gIIaTER:GASING'OR'TQBIiXG� "otliErmsd elofed3oo
2.Well Construction Permit#: 2 T'OC^WAI A'09GS- FROM TO DIAMETER THICHI4FSS MATtrRTAT- r_
List all applicable wel!construction permits(i.e.IIIC,County Slate,Yarianca etc) A. ft a.
3.Well Use(check well use): , R• to ft in 941 V0;z
Water Supply Well:
FROM TO DIAMSr&B SLOT SITS TIiIC10,tZrSS MATYR111.
❑Agricultural ❑Municipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) 64esidential Water Supply(single) ft fL
❑Industrial/Commercial ❑Residential Water Supply(shared) v
❑hri ation ❑Wells>100,000 GPD FROM I To MATERIAL EMPLA MMOD&AMOUNT
Non-Water Supply Well: 0 ft. ft rr .t;
❑Monitoring ❑Recovery ft. ft. l v� + J
Injection Well: V
ft ft
❑Aquifer Recharge ❑Groundwater Remediation
19:sANIi/GRAVF�IjACK`it a licalile
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL F.NIPLA METHOD
❑Aquifer Test ❑StormwateiDrainage ft' ft
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer 20:DRT[S1NCy'LOG ittkcL additio`"!hieti if uecns "
❑Geothermal(Heating/Cooling Return ❑Other( lain under#21 Remarks) FROM xo DESCRIPTION eoIDr,h:rdnw sotllrroek s>u ere
ft. fL
Date Well Started Le^
4.Date Well(s)Completed: 7^ Well im 2 ft ft
5aWellLocation: 'Phone#:Ik334- 42-u�� ft. ft H 3 34,C"7 V-%S7J73 fz ft
Facility/OwnerN Facility ID#(if applicable) R ft. to,
IL
J 70 �a��v Plea.Ian r (?-a ir-c �. R
Physical Address,City,an a-1313 ft ft tYt-a 5W
County Parcel Identification No.(PIN) 4
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
3S', 16 FrL o N 72!J `7l � 3 W I o�
6.Is(are)the well(s): permanent or ❑Temporary rep/&(-4e Si olTerodl Well on ctor Date- ' �' By signing thisfonn,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or QNo 2 15A NCAC 02C.0100 or I SA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the naive of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis 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 is needed Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24•SUBNIITTAL INSTRUCTIONS
9.Total well depth below land surface: .50 ' (ft.) Submit this GW-1 within 30 days of well completion per the following;
For multiple wells list all depths iit different(example-f3Ql200'and 2©100�
10.Static water level below top of casing; 1 S (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+" qQ Information Processing Unit,IS 17 MSC,Raleigh,NC 27699-1617
11.Borehole diameter- 4C (in.)Blt Off: r x 24b•For Wection'Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636 A Z
12.Well construction method: A 1, n�L 24c.For Water$nppIy 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 t
FOR WATER SUPPLY WELLS ONLY: " C
24d.Far Water Wells producingover lOD 000 GPD: Cop r�toDWR,CCPCA
�"r Permit rogrua,1611 MSC,Raleigh,NC 27699-1611 F�'^fV �/ t�S Q
13a.Yield(gpm) Method of test: �
70% hth ' Date Site Visited: t7(' Z
13b.Disinfection type: Amount: OZ Site Visited By:
Vc.►,•n.. htu i f Oh
S:+-s
Form OW-1 Nortb Carolina Deoartment of R„pjmnmantal duty-Division of Water Resources pe.(,i"tl- Revised 6-6-2018
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