GW1--04359_Well Construction - GW1_20240722

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.4:d11 Contractor Infor.iilion:
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a4 WATE$'ZONPS' %„ok '.
- FROM TO DESCRIPTION
Well Contractor Name
5 _J-4' 52af- g k: to G Pr1 Glcor-
fL ft
NC Well Contractor Certification Number T 15:IMIER'C'A`3ING(fu mnla u ediiveilsTORI,IIVER'(ifi►i 7ic97ili f.•;,,,
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS LMATERIAL
/ ft. {t l
CompanyNamc%t( MLie1 G�- '(i-' J 10 6 3 61 r ! !
�sTT U I �'r UCIDINIEi.GA..SING'OR IOIG leutlietmal clOkineop) `.
2.Well Construction Permit#: ( 2. '7 CPU e UI.z y PROM TO • DIAMETER THICKNESS MATERIAL l
List all applicable well construction permits(i.e.UJC,County State,Variance.etc) I ft ft j,�$ I i�[Q� l� .Za e/ °" c,
3.Well Use(check well use): fL ft II
t� U u S't etA
Wafer Supply Well: i37:WRiE i.... ,';::.- ';• ,.: .": •..;..: `:.':.:
FROM TO • "DIAMETER' SLOT SIZE ,•THICIINESS •,.•MATERIAL `)
ii icultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
.-
['Industrial/Commercial ❑Residential Water Supply(shared) l;•igm,-0 , ,: /).1/q
❑Irrigation ❑Welllss>100,000 GPD FROM TO MA ` EMPLAS•0,` OD&AMO 1 '1
Non-Water Supply Well: ft. ft (i'. Tick.i ,,,icti
DMonitoring DRecovery ft, ft aaa111
Injection Well: ft ft
❑ uifer Recharge ❑Groundwater Remediation
[Aquifer g 09.SAND/GRAV aP Cf (ifeipplic"abli)`!:r:
DAquifer Storage and Recovery ['Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD ' •
DAquifer Test ❑Stormwater Drainage ft ft
❑experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer ".20:I)RII IGI.OG(attith idditlou:illliiits if:neci sary)'' ' 1: ::.:!' :' ::,..:
FROM TO DESCRIPTION(color,hardness,soil/reek type,grain siu,eta) �•
❑Geothermal(Heating/Cooling Return) ❑Other(explainunder#21Remarks) ,yam.•
Date Well Started v7-/-a J
4.Date Well(s)Completed: '"�-1,� WellIil#AACR— '.3' 4�ft 2 .. t 1* -0 .('(171 j- ...-.00
Sa.Well Location: Phone#.2.39- 6•0.9-SS7S3 ft. ft
/ J ft. ft _ t
"a h,. �p� ��`
ft ft 1 _"1, a C.
Y.
f' 4- L''1
Facility/Owner Name Facility ID#(if applicable)
7 v 6 .5 n� tY,i;Ce41 /'..J rn ot., 1,4 ft. ft I_j«Tftr 4 G
Physical Address,City,and Zip NC.//. C 777ffV�� ��` s f lQr ft ft.
s 1,t21 ii EMAVAS: ilia„eiFx r -A; ,ysi.'c%a
County Parcel Identification No.(PIN) ��� a Laa a)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
3S. `IO 5'o T N 7 el. Ci 2 t 7 C w /'t;. 1 _ ,, _` - 7- — kr\
6.Is(are)the well(s): E11Sermanent or ❑Temporary SSiignahueof<,eRttied�ieWContractor Date
By signing this form,I hereby cerh,fy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or0 1SA NCAC 02C.0100 or ISA NCAC 02C.0200 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 provided to the well owner.
repair under#21 remarla section or on the back of this 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 I Gr.is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).Ycar may also attach additional pages if necessary.
drilled. 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 5 - (ft.)
For multiple wells list all depths((different(example-3(a)200'and 2Q100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: ) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level s above caring.use"+" (ft Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: C (in,)Bit Off: S/$$3 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
/I Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Al v E,as.Lts PG 14 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the C
(i.e.auger,rotary,cable,direct push,etc.) / county environmental health department of the county where installed to
FOR WATER SUPPLY WELLS ONLY: • 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
l,,, Q '�-/ Permit Program,1611 MSC,Raleigh,NC 27699-1611 i
13a.Yield(gpm) y Method of test: (C �y��1 Yl�'+�'�
o Date Site Visited: Z-2y•Z1 6:,e4 '
70/o hth ii Oz Site Visited B : D1 '
13b.Disinfection type: Amount: y
.�,s,
Form GW-I North Carolina Department ofEnviromnental Quality-Division of Water Resources Revised 6-6-2018
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