GW1--05567_Well Construction - GW1_20240913

ALL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
•
1.Well Contractor Information:
DIY� ,. •J,......:
V' ® 1I Q��`'1Nbi //) / C a.;1A.Wfi�`ZONES:•j:x:ors','.r•:•.:..i,','•: '.• . i-'>':+'" . ....: . . .. ,
nor TO DESCRIPTION
Well Confractor Name /� • 16ft 16rt_ 2 ''
� 566 '
2,z� .'t ,5 O rt 3 O `� . -�
NC Well Contractor Certification Number ;:1•S O'0'ffi7;.''_I1QG.(fdnmiiliireltsedNv :OIi
FIOifapFllcatilef'.'
Yadkin Well Company, inc. FROM TO .DIAMETER THICKNESS MATERIAL
+ I ft. 117- ft 6 0l t< 'in' .PI U 2/ PVC-
Company Name a' G_ORXIIBIblC(ge itliec aifireldiea16ir ::::;:
2.Well Construction Permit#: P.W I-3 O2 0l 31 Y. FROM - TO • _ DIAMETER TRIMNESS MATERIAL
List all applicable well construction permits(Le.Ultra Cow*,State,Variance,eta) ft ft in
3.Well Use(check well use): ft ft in ,
Water Supply Well:
FROM TO DIAMETER SLOT Sint THICKNESS MATERIAL
❑Agricultural ❑Municipa]/Public ' ft. ft. in.
❑Geothermal(Heating/Cooling Supply) sokidential Water Supply(single) ft it. in.
❑Indushial/Commercial Idential Water Supply(shared)
❑hrigation ❑Welis>100,000 GPD FROM�� TO MATERIAL , EMPLACEMENTMETROD&AMOUNT
ff
Non-Water Supply Well: . ; 8. / S ft °1:r O txdr— 4®f Am
❑Monitoring ❑Recovery ft ft
Injection Well: I ft.
DAquifer Recharge ❑Groundwater Remediation -
ft.
. i t19:SA2 D7GFtA'[T> PiCrtk.(iL tphcattie)s-:f --.-:"..-..7:•::.,.'_•• .. ...
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD ' •
❑Aquifer Test ❑StormwaterDrainage ft ft
❑Experimental Technology OSubsidence Control ft. ft.
❑Geotiiermal(Closed Loop) OTracer :'20 DRR.ISNG1OG(attitcli additioriarslieetaif:neeessary);ff:'-':4,_::::.s... : -
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 RPmarkR) 0 R z-7 ft a e Date Well Started 7_l,)—2.$ y�
4.Date Well '�—s)Completed: la:.`2ID
Well
#IM t 2$3 ft: LP-IL ft ',Jr..; 4
5a.Well Location: Phone#:636-233-iii(3.(5 5 ft 3 a rt a
AT�=Gr h, PEAG K e4.-+ ft. ft. % .`L. ,.�1,.... %•I S�i.
Facility/Owner Name' Facility ID#(if applicable) ft' ft. S F P 1 5 7 f l 2 A
/8� T�� f ft. ft �r
Physical Address,City,andZIp Nc 70y4t3 ft ft e „ '�•: Ian t'
County icier
--CU Parcel Identification No.(PIN)
5b.Latitude and Iongitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22 .:,cation: /
la
3(nta 32Ii' N c 44k 9.3-s. W ri 07 '0 • 1y
6.Is(are)the well(s): Lermanent or ❑Temporary Si . a of Well Contractor Date
By i.zing this n,I hereby certify that the well( as(were)constructed in accordance with
. 7.Is this a repair to an existing well: ❑Yes or Gaga 15 CAC 0 .0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out brown well construction information and explain the nature of the of this recur;has been provided io the well owner.
repair under 421 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 CI,W=1 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: 3 Al, (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Qa 200'and 2Q100)
10.Static water level below top of casing: 80 (ft) 24a, For All Wells: Original form 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: 1' (in)Bit Off: -5- i C 0 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:
(i.e,auger,rotary,cable,direct push,etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
county environmental health department of the county where installed
A
FOR WATER SUPPLY WELLS ONLY: • 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA a
t
(+ ,�✓ sa-i4 43-
13a.Yield(gpm) �4-,---1 Method of test: �t � Permit Program,1611 MSC,Raleigh,NC 27699-1611 Cry �
70% hth Date Site Visited: Et-3,) _2-y
. 13b.Disinfection type: Amount: ► Oz Site Visited By:
S
Fo..GW-1 ---- s North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
Pric-` 1