GW1--05556_Well Construction - GW1_20240913

NATAL CONSTRUCTION RECORD (G9V-1) For Internal Use Only:
1.Well Contractor Informition•
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Well Contractor Name 4 56 6 - �y FROM TO ...• DESCRIPTION
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NC Well Contractor Certification Number 15r0U1:1TROiSING'.(f6i`mulfi°"coded:iellss)`:OR ;(i 1'-'11 atilef;.1;v
Yadkin Well Company, Inc. FROM Q ,DIAMETER' THICKNESS MATERIAL
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Company Name
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2.Well Cpnstruction Permit#: V A FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits r.e.UIC,County,State,Variance,etc.) ft. ft. in
3.Well Use(check well use): ft ft in.
WaferSupply c.1.7 sc'-:E 2 "_:r:.:fir;;•:-,:2;i:Z.VLa -.,i1 --rr..•--,_-.1. -.;
PP 'Well FROM TO• ~u,•'DIAMETER SLOTSTm+ THICKNESS~ MATERIAL
t icultural ❑Municipal/Public ft. ft. ' in. .
❑Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft it in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) i:}18xGIio'UT :i -:>::,' ., - ::_ -.. :. ..
❑ltrigation ❑Wells>100,000 GPD _FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: ft• 5 ft. D g !St. �/' C,
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❑Monitoring - ❑Recovery ft. ft
Injection Well: ft ft.
DAquifer Recharge •❑Groundwater Remediation
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❑Aquifer Storage and Recovery ❑SalmmityBarrier FROM TO MATERIAL EMPLACEM.NTMETHOD ' •
DAquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology V ❑Subsidence Control ft, ft.❑Geothermal(Closed Loop) e ❑Tracer '.•20:DRIC3:IN@ZOG xtfa67i additianaY•sli'eed3f;neces M, ?.:,.::.;=::.A....
- ❑GeotheImal(Heating/Cooling etnm) ' Other(explain under#21 Remarks) FROM TO DESCRIPTION(colas:hardness,soitlroek type grata size etc.)
Date Well Started' a - La 0 ' 9?` iL 4)1 r-1 :
4.Date Wells Cam leted: 7 e! : W,• Well ID#A" - t��
Phone#' s3G- 2C2'� G u ft 11 ft' �� e %''.r 4_ r V� ,
5a.WellLocation: 2. i 'i' Q '
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'Facilityy/0ivnerName. Facility ID#(if applicable)' �) ft. 6.6® ft �� /
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2yy : bl'1 14w 60 (2,0,N A roc, ' . 6. ft. 76.6 ft t r ),cry�'raiay,:.;':,
• ,,PhysicalAddiess,City,and filo a COS ft ' ft
iL {-A Z1Y'RRM'ARYCR::.. .......% ..v r -..,..y.=.
County ,."' ' . Parcel ldrntificationNo.(PIN) ,
Sb.Latitude and loagitadein degrees/minutes/seconds or decimal degrees:
(if qwell field,one lat/long its sufficient) p 2/ ^ of ratio,
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for f Certified Well Contractor ' Date
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6.Is(are)the well(s): permanent or ❑Temporary i_
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: DYes or ISI 15A NCAC 02C'.0100 or 15A 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 GeoprobelDPT 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-J,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: 7_5 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(erample-3©200'and 2Q100)
10.Static water level below top of casing: (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617:MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" - .
: 24b.For Injection'Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter ft2 (in.)Bit Off: Program,1636 MSC,Raleigh,NC'27699-1636
12.Well construction method: CN �"l ' ✓ 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.auger,rotary,cable,direct push,etc.) r 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
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�f�� Permit Program,1611'MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: ,
oDate Site Visited:�-Z.-12'`7'
13b.Disinfection type: 70�o hth Amount: Oz Site Visited By: .673 ; 1
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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