GW1--04358_Well Construction - GW1_20240722

W?ok ,CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Inffrmation: n
�0 d ' / i f�'V 1 •
/L\ I , `c �C"- .14.WATER ZONES%<r'. ''�i '
Well Contractor Nine FROM TO DESCRiPT10N
y S l a = ft. -�� ft 0
ft. p ft 1 u d
NC Well Contractor Certification Number :15:OIITKR'CASING(for`multi,cased.welli)ARLINER:.(ifa'-licablej:::,
Yadkin Well Company, Inc. FROM XAMETER �T II}CKNESS MATERIAL _ C
Company Name /.5lek.awl er 9-2 itC.3 2- 10(:c o
1Ft., a 't' i ft' ft ,t 2�s in. 7� 'Z 1 PuC_ E.
p : 6tINNEWFACING:ORS:1•.0180 acithe rnli cln5la=loop)
5 !1 2.Well Construction Permit#: ` FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State, Variance,eta) ft. ft in.
3.Well Use(check well use): ft. ft in ^11
Water Supply Well: r 17: .CREE1�:'
FROM TO DIAMETER SLOT SIZE ,THICKNESS MATERIAL
❑Agricultural ❑M cipallPublic ft. ft in.
❑Geothermal(Heating/Cooping Supply) esidential Water Supply(single) ft ft in �.--"'
❑Industrial/Commercial ❑Residential Water Supply(shared) 18 GBOU'T'.'`
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
I
Non-Water Supply Well: 0ft' 23 ft. �nsi:+,�,� , POia V', `4""474(j14- O
❑Monitoring ❑Recovery ft. ft
Injection Well: - -
ft. ft
❑Aquifer Recharge ❑Groundwater Remediation (0
i'19.SAND/Gft'AMiPAC .(if-appll'c'sbte).'l . / n
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD ' - V7
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ftN.
❑Geothermal(Closed Loop) ❑Tracer •'20:DRITfl1t&LOG(atticti iddittncal"slieeti if'uccess'a y)','..... .C''':':.:: ..:':' ::"..;-.
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Re�11� ❑Other(explain under#21 Remark:.) ft. L s) ft. �q
Date Well Started 7—Z) - -L. `1 4.Date Well(s)Completed: 7-9-2 l Well1D# 4/14-2344 2 5 ft. 9ft. r•®i,.-y
-,
5a.well Location.id a tr ! Phone#:g/S2-2 7--/9 ft. P 2 t,ft r4.311.-. -. . .ti ''�
/ ` .f e 1 t e i I^el t `�►�I, �TJ l/ Q,..J'{� IlOfr 4 ft. ft . .. �, �.. R i _L ? 3
r P �
Facility/Owner Name Facility ID#(if apptcable) ft ft
/ rt. ft
13�` .kvi-erinAire Ste„ey A/nf ?::$
Physical Address,City,and Zipa�1 • a���Q1 ft. ft , Jam, --.
l��ld h c+_C'►' O 1:21`1tEMARES. . ., ;t�' '.C1.: .. ... .: ... .
CA
County Parcel Identification No.(PIN) —
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 4
(if well field,one lat/long is sufficient) 22 C tiflcation:
3S: 7g02,i- N gi, k) 7J-1 .‘,„
(--,,,A1-- 9
6.Is(are)the well(s): 1R3'ermanent or ❑Temporary S e C ed Well Contractor Date
/ By signing th'form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or o 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy 1,
If this is a repair,fill out known well construction information and explain the nature of thc of this record has been provided to the well owner.
repair under#21 remark section or on the back of this form.
23.Site diagram or additional well details: ra
8.For GeoprobelDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info La,
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 INSTRUCLIONS
9.TotaI well depth below land surface: (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@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"+"
60
11.Borehole diameter: 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
(in.)glt Off: s` Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: /A!✓ / A+41l Da f 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the k
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed 2
FOR WATER SUPPLY WELLS ONLY: • 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
/^ Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 2V '4"
t• Method of test: G;t\l ri _
70% hth 0Date Site Visited:
t q
13b.Disinfection type: Amount: 'f OZ A Site Visited By: D1fl' J Z
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Form GW-1 North Carolina Department of Enviro.imrntal Quality-Division of Water Resources Revised 6-6-2018 �' �"
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