GW1--05526_Well Construction - GW1_20240913

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CONSTRUCTION RECORD (GVV-1) For Internal Use Only: -I
1.Well Contractor Information:
©C) , T4i-WATERZANES ;i' ,-...i. I -- ,.. .
Well Contractor Name FROM TO DESCRIPTION
,n l�
v/� C 1 •
... i-looft ttoc.S" 7.. Plv1 Clear
ft ft _-- I. i __
NC Well Contractor Certification Number /. f' S. r
p Y� Inc. f15:0UJ$,:asrtlo umula 5earwev7ol:> ,Gf '>f s21 -:_ .
Yadkin Well Company, FROM To .DIAMETERS .• THICISS MATERIAL
ft. it :in: ^...<,..
Company Name
�� � p S-16S/NRIICGASIPIG:01t,TlIBILWir itbeimllatrignakil. •: --"::
2.Well Construction Permit#: O `4 FROM TO • DIAMETER TBXCENESS MATERIAL
List all applicable well construction permits(i.e.WC,Comity,State,Variance,etc) '1 ft )1 V ft 'lY n.17111
i171 in' ,Cv�Dl��'1, V& `%'
3.Well Use(check well use): ft ft C in 0�
Water Supply Well: r"37ilC$E .<'4i ;,<5 _ _,.. ._: ::;.. '=!:.
FROM TO DIAMETER•• SLOT 5I2E THICKNESS MATERIAL
❑Agricultural ❑M�unicipal/Public - ft ft ili '
❑Geothermal(Iieating/Cooling Supply) ®'Residential Water Supply(single) ,, ft ft in i -
❑Industrial/Commercial ❑Residential Water&rill y(shared) .:»: _ i:r..--,,. c.---,•..a:,,,4..----.
❑Imgation ❑Wells>100,000 GPD •FROM TO _MATERIAL' .' EMPS,>CEMENT METHOD&AMOUNT ro
Non-Water Supply Well: ' ' a ft. (3?ft. Bein C4lls 91uy 26 RoeS
❑Monitoring ❑Recovery ft. ft
Injection Well:
ft ft
❑ er Recharge ❑Groundwater Remediation -Aqurf arg ii'19::BAND 6TeiMMI,A77Kx iMP"$1ic€ll1e)r a::'-"' - ..Z.5:.-a .- -c_:__=y+,r-'::::.,
METHOD -❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT
❑Aquifer Test . ❑StormwaterDrainage ft ft
❑Experimental Technology ❑Subsidence Control ft. ft - j
❑Geothermal(Closed Loop) ❑Tracer ,t 201DRILtlNGZOG(attach additinn`aT"slieeeti'iftiedeisefy)i�7:°A: i"':`:a`s' s,'' w<:: ,,,,�
❑Geothermal(Ileating/('OOliII Return) 170thei FROM TO DESCE PTION(color,hardness,solllrock type,grain size,etc.)
g (explain under#21 Remarks) ft �l
Date Well Started 7/t�--, ay I
4.Date Well(s)Completed: �"1)--9i,L WellID#,4 2-r-� 6643 ft ft r p.. �eJ�.
Sa Well Location: •phone#:33C° %C -C '2. St) ft. 1tgA,ft /-6Cit7 1_ rrT9,g -s ��
q , �PA',t.Eh�9. /e3Bei ft. 1J ft.
i/�Pl 1 1�- �p�
1 ve". Q ®thaw . , .. •
Facility/OwneiName /-y ,''FacilityyID#(if applicable) ft ft r• r+y�,..4., �.
Physical Address_City,and Zip. ,, ve,v sn or ft. ft. S E P 1 e 2D21 D
ed.k I r, , • • , ,..,. .. •'if4:::.9,:'ir 7 r,r
County Parcel Identification No.(PIN) ,t +tom ;c3 I]Aa
lr"ieLerr*t,JV
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ,
(if well field,one lat/long is sufficient) 22.Certification: y
gC„ (,�0 `$. N • 9'O. 4Rq®6��. w a 1-,I o -
6.Is(are)the well(s): l manent or ❑Temporary Signature of C ' ell 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 QN° 15ANCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out Mown 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 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 land surface: Li1-1 z (ft.) Submit this GW x'within 30 days of well completion per the following:For multiple wells list all depths if different(example-3(200'and 2@100) y P
10.Static water level
�"CD 24a. For All Wells: Original form to Division of Water Resources (DWR),
below top of casing: / (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is aboveecasing,
sing,use"+"11.Borehole diameter: • L (in.)Bit Off: 5,99
9. 24b.For Injection Wells: Copy to DER,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:A-iv' 1 ®ti' 24c.For Water Supply and Open Loop Geothermal Return Wells:Copy to the k-1
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed Z
FOR WATER SUPPLY'WELLS ONLY: • % 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield7 A' 1 Permit Program,1611 MSC,Raleigh,'NC 27699-1611
(gpm) Method of test: 4-
° Date Site Visited: X''Z-,3 '2- P
DI
13b.Disinfection type: 70�0 huh Amount:_ l' Oz Site Visited By: Oi7ti I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water,Resources ' Revised 6-6-2Di8
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