GW1--04393_Well Construction - GW1_20240723

WELL CONSTRUCTION RECORD (GW-1' For Internal Use Only:1.Well Cot.racto Information: ``1r)
M &/1 k_ g v tW.fk WATF.0 ZONES'3 Lam' :
FROM TO DESCRIPTION
Well Contractor Name 71 ft 40 it 'n� 70 I - a �/�I
yr,.
3 F� 7, <<t i ft ;� -0 it ,A� UI a 711 3V oi, `v
NC Well Contractor Certification Number :15.sOV1 .CASING`(foimulti=ersed"welTs�':OR:LI NEB.'(ifa�7iailef: g-1
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS i MATERIAL ft. ft in _��D//��
Company Name V L
/ A b16`INNERCASiNGbR QBIP,IG:(Aeatli rm-s'1 eliiiinoo"7° . ::.
2.Well Construction Permit#: /d l FROM TO . DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(n. UIG County,State,Variance,etc) L ' ft. get ft. /,x m- , )78 r f- -�� t'•••
3.Well Use(check well use): T ft. O ft V In. v �y
Water Supply WeIl: J.
FROM TO DIAMETER SLOT cr7N THICKNESS MATERIAL
Agricultural ❑Municipal/Public ft. it. in.
Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft in.
❑Indushial/Commeacial ❑Residential Water Supply(shared) F'18?,GROUT:.': ..'. .. .. .. :
❑Irrigation • ❑Wells>100,000 GPD FROM TO MATERIAL / EMPLACEMENT METHOD&AMOUNI
Non-Water Supply Well: a ft. a3 ft ar1�Ci�Te Cis t l P✓t.rt
❑Monitoring ❑Recovery ft. ft r-� --- -. _ i
Injection Well: ft R ` r., S•. o'•••..} /, �--_
OAquifer Recharge ❑Groundwater Remediation
+'19:SAND) lit alik (>fsIff i cabrer ' • I 4-Ct tT M •
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL D •
❑Aquifer Test ❑Stormwater Drainage ft. ft
t'/J. kt l l '
❑�Perimental TechnologyID Subsidence Control ft. ft Dt: .�,
2,1
❑Geothermal(Closed Loop) ❑Tracer ':20:DRIf 3IIGI:OG(ittichlidditiiiiialliiiiti if necessary)'.'::1'h:d. ';ii..::•'.1.;.;
FROM TO DESCRIPTION(color,hardness,soil/reek type,grain size,ern)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
Date Well Started -7 -244. ID
/ /� /) / 1"? -So-` /
4.Date Well(s)Completed: 1,i-4 Well # /•••r/7 Q� / '7/_ la ' let ft psi..., f p c k
5a.Well Location: Phone#:$2$'.`7 7 3- 431 '' ft. 3 7 ft S 1/ .- -
it
,4'CI(//n j.1J ota,AitJ f3? ft ']q ft. 3,0� '4.7 ., nil C
Facility/OwnerName Facility lD#(if applicable) / q ft- T7d ft y1Ld .. 9rodki///� .
R.t)3 k ¶(4AC k £ cv 6tnr� 17 ft. 50 ft So ['K 3/Cook rOC'"
Physical Address,City,and Zip ry p 6.,9 q 0 ft ie ti ft ^1 ./ 5 v r.8.�./�g ..�-
�f,Y ';21"RH XA`RYcs;: ~ '
VV T 'tUc c` - •, `�l _ �`Y�': fo rtt� rcc.(C.:....' /may
County Panel IdmtifiraHon No.(PIN) i/ $r
5b.Latitude and Iongitude in degrees/minutes/seconds or decimal degrees: ( F O� s 're r f T�
(if well field,one latflong is sufficient) 22.Certification: ,�+�
• 3b •,� 8 X p i z N a 1 i 83-0► '-I w C._ 7.-( - ?-i-t E-
6.Is(are)the well(s):itermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this 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 Io 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well canstn stun 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 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 1 GW- is 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 and surface: 10 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3©200'and 2Q100)
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 casin&use"+"
11.Borehole diameter: 6 (in.)Blt Off: 6' 11 S 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC) ....
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 4// to 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: • 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
,t Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 5 Method of test: I'/ Q./ G u
o Date Site Visited: p -Z /
. 13b.Disinfection type: 70�° hth Amount: ? OZ Site Visited By: M
6 Ct
c)IT
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
Prieto'