GW1--06882_Well Construction - GW1_20241118

4 E CONSTRUCTION RECORD (GW-1' For Internal Use Only:
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1.Well Contractorw] Information: a'
nc wit 1 t II0 f'" LA i r j' 5 .r/. .X.4i.WA�$57ANES`".:'�' ..a ::S'r.'..'r;•;: .. •. ,`•r. f� .
FROM TO .•'�+ DESCRIPTION
Well,Contrac NSIDe m d I (j S ft ft �] C I _/1
"i C2 Li /— pro.
. 5 U w9'
ft it , , ('�
NC Well Contractor Certification Number , ,-„
is1.5.''OIITEF1::ciLSIld.G'(fuz�mnlfi:case$;zreIIs7:ORIiZI•TF�R�(if`sP"liralil6f , %'.
Yadkin Well Company, Inc. FROM TO DT.M 7ER THICKNESS MATERIAL 1
• Com an Name b ft Li 6 ft. 6. 1 2 5 in. S1)1-1. 1U(,
P Y ® Sys if6aNNFItGAS3NG'ORMUBING_' •o'ttiei�alrloseTloo ic:_:i:=ter: ..' . .,
2.Well Construction Permit#q�* ""6/ c ix- FROM TO . DIAMETER THICKNESS XMATERIAL�
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft it • ro-
' 3.Well Use(check well use): ft it in
•,. k.
Water Supply Well: co Sri[2,ft ,co,s:I.. __ :,:::'>s ";F:. : ,iA-:,:r C..:� ` •_:
FROM TO DIAMETER SLOT SIZE<. THICKNESS MATERIAL
❑Agricultural ❑ ipal/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) IMential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) x j •..c,:.: ,. -- —_ M •
❑Irrigation ❑Wells>100,000 GPD _ FROM TO XIATERIAL EtWLACEMENT METHOD&AMOUNT
Non-Water Supply Well: R, 26 ft
❑Monitoring DRecovery ft. ft S
Injection Well: ft ft.
14)
DAquifer Recharge ❑Groundwater Remediation ]r. - r
❑Aquifer Storage and Recovery ❑Satin ry '•>19::SA D/R J 'ACYktifiippi cab5ej :: .s.:::�,:-.. i';.__>,�':' ..,_._,_'-�
I Barrier FROM TO MATERIAL r EMPLACEMENT METHOD (14
DAquifer Test ❑StormwaterDrainage ft ' ft N. of
' ❑Experimental Technology ❑Subsidence Control ft..
❑Geothermal(Closed Loop) ❑Tracer • 1•:20 IDILI!'l_,IlVGT:OG.(iittac7taadition"iIslieet3ifrie'c'nsiky—I.Z.:_ ='.--`%tis,`'-;'
❑Geothermal(Heating/Cooling Returo ❑Other(explain under#21 Remarks) FROM TO- D>3SCAIPTTON(color,hardness,sou raek type Brain sir etc 3 _
)
Date Well Started (®-'/.Z- W • - }}�� a ft 21• • 0.(74.fi .
4.Date.Well(s)Completed:i10'1-1' Z4 Wellm#Aka-3®-r Z 5 ft. 14 7 ft aTa^1Yl' - �:
5a Well Location Phone kg#:3X,VC'7-092.3 4 ft. S22 ft l9 rikri ,I, t
�i^�!d�' /�rre?I 1r �jt Fry=G&1/ 6� f. ft __
e. vmr^
!' • . • Facility/OwnerNaaie'1 FacilitylD#(if applicable) • ft :i.:,.-, :;Q '
2g&Ss 5rfiei .) k rh,/LS g4le s 9M(• ft ft. 'JO ti' i cuC4.,:...
Physical Address,City,an p . •. - •. -
County Parcel Identification No.(PIN) "
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: • -
(if well field,one lat/long is sufficient) 2 . tificati n: •
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(®, O3$1'd N gO0 1 1732_ W r ' 1 U 4-15.7 2_
6.Is(are)the well(s): permanent or OTemporary lure of C • Well Contractor Date
�� signing this f n,I hereby certify that the well(s)was(were)corutructed in accordance with t.
• 7.Is this a repair to an existing well: DYes or [WIC ISA 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 tinder#2I 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 t�
construction,only 1 a 1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary. `''1
drilled 24.SUBMITTAL INSTRUCTIONS
5 2 �J
9.Total well depth below land surface: LI (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifjerent(example-3Q200''a�nd'2�@100') „-
10.Static water level below top of casing: (2,- (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"+"
11.Borehole diameter: (ini Bit Off: 5. 9 86 24b.For Injection'Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Arir `.® 'y 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
FOR WATER SUPPLY WELLS ONLY: • 24d.For Water Wells producing over 100,000 GPDi Copy to DWR,CCPCUA C9)
'/' Permit Program,1611 MSC,Raleigh,NC 27699-1611 n
13a.Yield(gpm) Method of test: t/`-! �,%e 20.. 1..
• 70% hth 1�`i� Oz Date Site Visited: 8-1 -
2.4
• -- 13b.Disinfection type: Amount: Site Visited By: ozer '
•
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources ; Revised 6-6-2018
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