GW1--05538_Well Construction - GW1_20240913

WELL CONSTRUCTION RECORD (G'W-11 For Internal Use Only:
1.Well Contracto rmation• 3
:.I.4 A.TERZONEss3_a',.. ,:1,__ ,:t,:.1 3.71. .1'22.:�;312.t7p:.1:..<:` .-i::,
FROM TO . DESCRIPTION'
Well Contractor Name • ^ ¢�
J J Li? -� l� l it. 21� ft 09�IM
NC Well Contractor Certification Number �' l�� r' G '� vC
15.'OUTER'CASING`(formulti!riliie wells):ORLTNEIti iti.p lielalilee) :-.1'`s'.•'?.;`;
Yadkin Well Company, Inc. FROM TO DIAMETER I THICKNESS MATERIAL
ft. ft yin.
CompanyName • io
�� `.i16:1 NEIVCASING.OR•xuBINGifg'a'otlierinirclo`ed:lnop)':i1:1. "w_ T,
2.Well Construction Permit#: LI. FROM TO DIAMETER:' THICKNESS MATERIAL.
List all applicable well construction permits(i.e.UIC,Colony,State,Variance,etc.) ÷ B ft. kg ft G,(2�,in• ('O/) L, e 1 iC_
3.Well Use(check well use): jr ft ft in. ✓ t� V
Water Supply Well: r ''�
a77'S.C12EE) z< f ~:Gi.� 1 __�_a._�* Y )
FROM TO DIAMETER 'SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public ft ft in. .
❑Geothermal(Heating/Cooling Supply) esidenfial Water Supply(single) ft ft. fn.
• ❑lndustrial/Commercial OResidential Water Supply(shared)
❑Irrigation ❑Wells>100,000GPD _ FROM TO MATERIAL EMPLACEMENT METHOD&AMODNT_
• Non-Water Supply Well: 0 ft. al ft R.,r.4.4 ii+'e C4 fp S ��VIA,.
DMonitoring ❑Recovery ft ft. • �/
Injection Well: • ft. ft l ���f
❑Aquifer Recharge ❑Groundwater Remediation
❑A uiferStora Storage ❑Salini Barrier id19 SANli/GRA'VEGPACK(ifspplicable) ^:''C' r ,; _ -- .
Q g Recovery Salinity FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test ❑StormwaterDrainage ft ft
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) OTracer r:20 DRT33SIGlOG`(affaa7 additionalsheefaifnecrssary) ` _ `
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,son/rack type,grain size,etc.)
Date Well Started ')-(I6-I-�4 //�� pp��' ,, 0 ft' ? ft ° ,i JJ--
4.Date Wells)Completed '1-Pi Well.ID#,AAA, a 0 ? ft is ft Qra w.,, /cc, k •
Phone#: 5.9k- 914I_ V/01 f 6 ft' . 31-1 ft. S6401' Jo. / .
52-Well Location y
!� 1,,r g28- f(1•"3111 35 ft. 302.ft. t11rJ rbavd0 / nt�'`
Cad •' �1G';�u41� �r ft ft �
Facility/ Name Facility ID#(if applicable) "" L f I. /7: )
";ig, -,.. ';...,;
/a �+v ft. ft. .'q.p aw , r t
®m I .si,� �ACf �� ft ft (����� L� 1 Physical A s,City,and Zip `I C' y ! 24
11::ftEILIA lKse4-i-z`. t-1s, 17 *? t
County Parcel IdentificarioriNo.(PIN) 1?�5 ;`.�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/longis sufficient) 22.Certification: .
l® N s.1,0 jitr `® W 001.4 ,UWll .c wV-e- `]-(1- a q
6.Is(are)the well(s): r'ermanent or ❑Temporary Signature of Certified Well Contrac r Date
By signing this form,I hereby cert fy that the'well(s)was(were)constructed in accordance with i�'.•.;.
7.Is this a repair to an existing well: ❑Yes or Xko 1SANCAC 02C.0100 or 1SA 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 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-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over inRemarks Box).You may also attach additional pages if necessary.
filled' I • /( 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �Vr , (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q200'and 2Q100)
24a. For All Wells: Original form to' Division of Water:Resources (DWR),
10.Static water level below top of casing: (fti) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" (�
11.Borehole diameter: _(in.)Blt Off: Cr 1 U 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636 C9
12.Well construction method: t/ ez, i3r 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 ro
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producingov r 100,000 GED: Copy to DWR,CCPCUA
(gpm)
5-0 f Permit Program,1611 MSC,Raleigh,NCB 27699-1611
13a.Yield Method of test: If� a~ e ,.
70% hth I OZ Date Site Visited: If f 1J
13b.Disinfection type: Amount: Site Visited By: „Ai 6 I 1
lJr 1 r
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
Price: 5.4 Cstm ir r.a.c