GW1--05460_Well Construction - GW1_20240912

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WELL CONSTRUCTION RECORD(GW41 For Internal Use Only:
1.Well Contractor Information: - '
\erri (jQ41Cl✓1 S .4 WAIIEIZZONES^t t•.• ..4•_:' . - :.:7..:,.. .. .
Well Contractor Name FROM TO •'•` DESCRIPTION 'I
5 i4 `'
()LisaA ft. :. ft 1
NC Well Contractor Certification Number ;'15."OUTER CASING'(for•`mtilti;c°cilsertiiens`AR'I IER:(iffiric`a ilUkia3 ?:...-•-..
1:" Yadkin Well Company, Inc. FROM TO DTAMF.TER THICKNESS MATERIAL
ft. ft in.
Company Name .
ZIAI R:C9SING'OR•ruxilNG:(geotliesmalclose lo6'ji)'•-.u; :;nil:..... .,
2.Well Construction Permit it: FROM TO . . DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(.e.UIC;County,State,Variance,etc.) ft• ft. in.
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• 3.Well Use(check well use): ft ft in. i
Water Supply Well xo•-7:SCRE 'i'r..,:,•Fro 455 1.1• i:"•-u;,2:F=V:.: :'�-=I::ice. ..i':
FROM TO< DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipa]/Public ft. ft. in.
' ❑Geothermal(Heating/Cooling Supply) Xlesidential Water Supply(single) ft. ft in. •
❑Industrial/Commercial ❑Residential Water Supply(shared) :r:a.- _.:.,,••.,. - T-1�t _,,,.
y18 [4i2Q11T,:,?�• :ia: �.�, ... b1: 1 _,. .sue
❑hrigation ❑Wells>100,000 GPD FROM TO w MATERIAL EMPLACEMENT METHOD&AMOUNT_
Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery ft. ft
Injection Well: ft. ft. -
❑Aquifer Recharge ❑Groundwater Remediation
:•19::SAND%GRA`VE bYACl0!(if5 iccthl j.aai:':i._ i--1:i°c••6:Ml+":'>4' u_
❑Aquifer Storage and Recovery ❑Salinity Bather FROM TO - MATERIAL EMPLACEMENT METHOD - •
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❑Aquifer Test ❑Stor mwater Drainage ft. ft
❑Experimental Technology - ❑Subsidence Control ft.. ft
❑Geothermal(Closed Loop) . OTracer s20i32010 INGIOG'(gttiiel aditioriinlieetii'id.ie'ressary`); . . ft.-. r'S'.1, <ati
FROM• ❑Geothermal(Heating/Cooling R tns ❑Other(explain under#21 Remarks) TO DESCRIPTION(color,hardness,soil/reek type grain size etc.) •
Date Well started -y1a4 �'� y�//�^ 3� 22l9 . 44 G ranile
4• .Date Well(s)Completed:,113013,1., Well ID#14 a"
5a Well Location: P• hone#4LIS— 406—Ne{d1 ft ft r. _
Leo goti e..ro , ft ft. I .` `.,L.:: V lwL '
Facilitly/Owner Name • Facility ID#(if applicable) I" ft. ft SF P 1 2 ?n24 <
i J 1 Li 1 D 00,1 Goat oa t I mAel el f': t co ft. ft
Physical Address,City,and Zip - `�' ft. ft (rdc.l t t, ,; t•'c.r:/"".r.s 1•hne,
Ash R,, ':21j1 zmalcs;'•.,:R.,.1Sf=..r'a±°....... ..=:<r:?'.n.-. ...-..i;i•:.i;": .'.::::is 7'... ........
County Parcel Identi$cationNo:(P114) • b r 1 1 I be r co
5b.Latitude and longitadeindegrees/minutes/seconds or decimal degrees: " m&k1 6 Gem • 44- 601+Ohry ( b) �8
(if well field,one lat/long is sufficient) . . - - 22.Certification:
• 3t 0 lot/ 5-5-•i/ N SSda .07611 .J' 1" wja,d,6,e„tiAlfasi — ?13oI ay6.Is(are)thewel(s):permanent or • OTemporary ofCetttWellContractor Date
By rig,ring this fonn,I hereby cerdi fy that the well(s)was(were)conshucted in accordance with rl
7.Is this a repair to an existing well: DYes or *No 15ANCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a copy -'
If this is a repair,fill out known well construction in formation and explain the nature of the of this record has been provided to the well owner.
repair under#21 remark section or on the back of this Aim.
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 TOTALNUMBER of wells (add See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: / ^^r- 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: q O '• (ft)
For multiple wells list an depths f different(example-3Q200'and 2Q100� Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 2 00 (ft.) 24a. For All Wells: Original farm to Division of Water Resources (DWR),
If water level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.)Bit off: ,'3"813 24b.For Injection'Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC27699-1636 •
12.Well construction method: &"a" (b 4-nry 24c.For Water supply and Open-Loop Geothermal Return Wells:Copy to the 00
(i.e.auger,mtary,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
` Permit Program,1611 MSC,Raleigh;NC 27699-1611
13a.Yield(gpm) Method of test: �f� it( ! 4.
c h p Date Site Visited: / 1 i
13b.Disinfection type: 70�o th Amount: /® OZ Site Visited By: ,VI�n' Cf
Form GW-1 North Carolina Department of Environmental.Quality-Division of Water Resources Revised 6-6-2018
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