GW1--05555_Well Construction - GW1_20240913

WEI. .CONSTRUCTION RECORD(CW-I1 For Internal Use Only: --`*
1.Well Contractor Information:
„S.19c.WAtE:EtzoN1';sztri.'a z-.:..ef>•: ,.'t.. - _
FROM TO DESCRIPTION `
Well Contractor Nafae ft ft
45 (4 - A t`t
N Jay ft ft fyM7
NC Well Contractor CertificationNumber g e
_1.5 ODIZR;:GI5IING'.(fo mull easedNe110:OR2NETiAidap"lioatilaf
• Yadkin Well Company, Inc. FROM TO p� .DIA T1�rR TBICnC ESS MATERIAL Ch
Corn aAy Name • •}• I ft Lf'6 ft 6.IZ� in. dc —�1 w e(/�
7 1 1-6S N!..TI:R;CASING:ORxnBIL`IIG(gialiet:maril�tas✓�rga•3ao'i';' 10f,;-nL-.
2.Well Construction Permit#: a V V • FROM TO • DIAMETER THICZNESS MATERIAL
List all applicable well construction pen nits(i.e.UIC,Cowny,State,Variance.etc) ft. . ft in. ""
3.Well Use(check well use): ft ft to
Water Supply Weil: • FROM TOy ., DIAMETER1 ' SLOT cT9I THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public •
❑Geothermal(Heating/Cooling Supply) tM esidential Water Supply(single) ft ft - in!' . '
•
❑Industrial/Commercial ❑Residential.Water Supply(shared) I18n6,A—ai T.<.„r- s,A-:: ._ `ry r -"
❑lnigation ❑Wells>100,000 GPD • FROM TO° :tMATERIAL , .ENIPLACEMINT METHOD&AMOUNT
Non-Water Supply Well: 0 . ft Z 2. ft 60„ Q-- pow r C l'iN. '`,'
}
❑Monitorng DRecovery ft. ft I . -s,.: ,
Injection Well: ft. ft. .
vim"
DAquiferRecharge •❑GroundwaterRemediation t j_ ��„ 4 yx . _
i:1 SAls`Il%GR DEL i,iiMit-Inf ea ej''s :'LZ dw :',: ;:
DAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL ENLP.ACEMENTMETHOD-. 7 •
❑Aquifer Test ❑Stormwater Drainage. ft ft ,
DExperimental Technology ID Subsidence Control ft. ft .
❑Geothermal(Closed Loop) ❑Tracer :20 DRf ENGZOG(ittnr7ce0ditioual"slieetiaCiiecessary) i :iiN.l
❑Geothermal(Heating/Coaling Rehm)_ 0 Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,sail/rock type grain size.,etc.)
Date Well Started tm 7 ` -iei-_.I4 " 0 2.? ft ,�e P.
4:Date,Well(s)Completed:0�-Z7-'Z CI Well.ID# •A Cat&'�'�� 2 6 ft 14IA1 ft: fA`ie
5a.Well Location: Phone#: 3 m"` -� �° (,� ft. I Z)()f t ,: o f'°�'� �q rt�R!`I' e P-�
eJ
Facility/O e±Name Facility ID#(if applicable) -
5 E�,.1 2024
PhysrcalAddress,City,and Zip • ��� �+� ft, ft ,
21' EM'A'RKC•!;' ..n >.._.. I.i..;s:1, y9s ,f ir +ems .r•� ..�fi;A
County - • Parcel ldentifi nation No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ;
(if well field,one lat./long is sufficient) 22 Iertlficatto-v:
• • 3C,0 12. ./2 N 5, C C W ' r .• ` iffrA
x���p - Z 2
6.Is(are)the well(s): ❑Permanent or 4emporary ed Well ContractorDate
f.ature.
igni :this form,Thereby certfb that the wells)was(were)constructed in accordance with '
7.Is this a repair to an existing well: . DYes or nNo 15A NCAC 02C.0100 o7'15ANCAC 02C.020O.Fell 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 thisform. 23.Site diagram or addilioAal;weil defaiis: , •
8.For GeoprobeJDPT 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�hVJ 1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks•Box).You may also attach additional pages if necessary.
drilled: r
24.SUBMITTAL INSTRiICTIONS
9.Total well depth below land surface: ' a®Ct, (ft.) Submit this GW4•within 30 days of well completion per the following: _=+
For multiple wells list all depths Vdtfferent(example-30200'and 2Qa 100� t I,
•��,t //l 24a. For All Wells: Original form'to Division of Water Resources (DWR), - •'.
10.Static water level below top of casing: J (/� (ft), Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" 4
S- 24b.For.Injection"Wells:Copy to DWR,Underground Injection Control(IUC)n -
11.Borehole diameter: (in.)Bit Off: Program,1636 MSC,Raleigh,NC 27699-1636
r 01
12.Well construction method: t fr �� 24c.•For Water.$upply and Open-Loop Geothermal Return Wells:Copy to the tru
(i.e.anger,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 GED: Copy to DWR,CCPCUA
13a.Yield(gpm) L- Method of test: Q Permit Program,1611 MSC,Raleigh,NC 27699-1611 w.'
o g� Date Site Visited: I ,
70/n hth• Amount: 1 - oz Site Visited By: M
. 13b.Disinfection type:
l
•
Form GW-1 :_North.Caitilina Department of Environmental Quality-Division of Water Resources; Revised 6-6-2018