GW1--04343_Well Construction - GW1_20240722

CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Informatio : f
t!�rC ['114 l 11`S �r as wATUZ0l s_:4...:
WcllContiactorName r— FROM ft TO . ft DESCRIPTION A�
rt ft.
NC Well contractor Certification Number v w-.. :.
15.''OUTEIZ'�A'SING fur lniilit-cased:weIIs`:O1ZLI�TF�; '"1i .• ..,..
Yadkin Well Company, Inc. FROM To DIAMETER xfficltl�ss MAxtrRIAL
CampanyName °C16INNER:GASILIGbR;T�Il`TGU dtlicrmiicloltedloo
2.Well Construction Permit#: Z O'Z, -� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits#.e.UIC,County,State,Variance,etc) ft % in.
3.Well Use(check well use): t:-
DIrrigationinwater Supply Well: TO DIAMETER SLOT SUM THICKNESS❑Agricultural ❑ cipal/Public ft in.
❑Geothermal(Heating/Cooling Supply) f9Residential Water Supply(single) ft in,
❑Industrial/Commercial ❑Residential Water Supply(shared)❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft, 2 ft !`K
❑Monitoring ❑Recovery % ft
Injection Well:
ft, ft
❑Aquifer Recharge ❑Groundwater Remediation
,c19.SAND/GRzVEIt1;.�• :�li'`c'n`ble�.,.,;.'• ,..•. ..... ....... ......
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL. EMPLACEMENTMETHOD.
❑Aquifer Test ❑Stormwater Drainage ft, ft
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer "'2D:3)R11.MGI.0G itt eddl6iiil'shiWifnecessary)
El Geothermal(Heating/Coolin Rehlm) Other(explain under#21 Remarks) xo DEscRiprTON color,hat daeu,ssulraek eta
Date Well Started .30— ��(( ft 7 ft t/`
4.Date Well(s)Completed: 'ZM' Well III# �'1� ��T ft. ft �' .
5a Well Location: Phone#: 3 '% ft. L� sit fy L�� S r;.w ,'I
ft, ft
Vo►aa14:-c-'11�r u h
Facility/Owner Name Facility ID#Cif applicable) R ft
ft
Physical Address,City,and Zip so o ft ft. `
FEW V AN 1 2�2E11�S
County Parcel Identification No.(PIN) UFA
-
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: fir't'd AC,3 .�
(if well field,one lat/long is sufficient) 22.Cer ation:
2,r*L y- N fs0. 3 f 3 2 2 w
6.Is(are)the well(s): 00ermanent or ❑Temporary Signa Certifi ell Contractor Date
By si >thisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or CW/O 15ANC4C 01C.0100 or 15ANCAC 01C.0100 Well Construction Standards and that a ropy
If this 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.
repair under#21 remarks 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 1
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.SUBMITTAL INSTRUCITONS (U
9.Total well depth below land surface: (ft.) Submit this GW-1 within 30 days of well completion per the following:
For mubtple wells list all depths fdifferent(example-3@200 and 2@100)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing use"+"
11.Borehole diameter, (in.)Bit Off: ® L/ 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: rA f 1��,}`s' ��
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(ice auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WLI.LS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) 4 Method of test: t/ Permit Program,1611 MSC,Raleigh,NC 27699-1611
70% hth ^ Date Site Visited: 3- -ZK
13b.Disinfection type: Amount: w/ OZ Site Visited By:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018