GW1--06887_Well Construction - GW1_20241118

�--'-' LT;,CONSTRUCTION RECORD(GW-1E For Internal Use Only: l
' 1.Well ContractoeInformation: _ ' ' 'P:,9 ;
•
Aec wQ,'I eA iiii.w.A. ZONES•_':t :::. .. • 1
Well Contractor Name FROM TO DESCRIPTION
I • ft 10 ft 1// GPNI ..
.V i S ry / - 3" ft 2/�/Z CPS ,.
NC Well Contractor Certification Number
Yadkin Well Company, Inc. rls!bu :cAS/NO`adi:m;illi c ed raUs :ORT R;(ifg'� i sleS::.:::`:._ • .
FROM TO DIAMETER. THICKNESS 7 MATERIAL I
ft. ft in.
Company Name
.;T6 mm iossmIG:oival BING:(nurser areloiealoopr.. 1
2.Well Construction Permit#: 'i/7 (5 FROM TO • D THICKNESS MATERIAL If
List all applicable well construction permits(Le.VIC,County,State,Variance,etc.) ' 4-1 ft 9 q' ft 6 in •j r8 a fb v —
3.Well Use(check well use): ft ft in.
Water Supply Well: s37s. ._....,.•, .._...._._...._
ll/ FROM TO DTAMF.TER SLOT SIZE THICKNESS MATERIAL ✓1
gricultural DM crpal/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) C111�sidential Water Supply(single)
ft ft in.
OT...strial/Commercial ['Residential Water Supply(shared) _ ....
u. •"gation DWells>100,000 GPD FROM - TO r�MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0' fr. ' F�a0 O[e ?kit RV fa•C.) ., -5:
['Monitoring DRecovery :ft. ft J
Injection Well: ft ,• ft. '
. DAquiferRecharge ❑GroundwaterRemediation _
r19::SAND/4RANx17-14..GK( p'c iIa)"•:::;;':: ::i";• - .
['Aquifer Storage and Recovery ['Salinity Banner FROM • TO MATERIAL EMPLACEMENT METHOD :
DAquifer Test ❑Stornwater Drainage ft ft
['Experimental Technology •❑Subsidence Control ft ft
❑Geothermal(ClosedLoop) ❑Tracer i201DRTf 'INGI:OG(itfaclinadifl itifiLeetsif:riecessacy)`:':.': ,'. �3
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,Hardness,sail/rack type gain sire eta) �G
rm
Date Well Started fr)12.1 S �j �,/��, p 0 $�v ft Sod I
4.Date Well(s)Completed:101 yI 241 Weum#/"C��(�` �G ft 80 ft /�aA 1 It
5a.Well Location: Phone#: Q2,f.,203= a5 ft. O ft la ice"
\ Faafk ails Caolr a ete(flitcy ':
ft.
k. Facility/OwnerName y Facility ID#(if applicable) ,ft. ft. �h
k 5 /24 1"ic2 G'rj($y.4-�at�• Ric) ?SOPS'S ft • ft. I, -. -' . . )' l3
• PhysicalRR Address,City,and Zip �J ft. ft td i)\i 1 S (I'J L t) 0)4
&Cite CA,�' • ..:,215RFTAA12YtS.:'.:;`s;-:.`:::i .. . ,... . -
County Parcel Identi icatioallo.(PIN) _• .. - - .
5b.Latitude and Iongitude in degrees/minutes/seconds or decimal degrees: •
(if well field,one lat/long is sufficient) 22.Certification: '
���: 7.S01Y N Wo15d "sc).s • W w lo•
ud f. `t
6.Is(are)the well(s): �ermanent or OTemporary signa4t ire of C ed Well Contractor Date
By signing this fonn,Ihereby ceral,that the well(s)was(were)constructed in accordance with 0
7.Is this a repair to an existing well: ❑Yes or Mt< 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. v
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details: ru
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 OW-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 1NSTRUCTIONS '' 40
•
9.Total well depth below Iand surface: O) (ft.) Submit this GW 1 within 30 days of well completionper the following:
For multiple wells list all depths If different(example-3Q20 and 2©100') y P
30 ft - 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below tap of casing: ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" •
11.Borehole diameter: G (in.)Blt Off: ®� 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 1 f 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
ry(ie.auger,rota ,cable,direct pushy etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: • 24d.For Water Wells producingover 100 000 GPD: to
A Copy DWR,CCPCUA
13a.Yield(gpm) 3 Method of test: /+4( Permit Program,1611 MSC,Raleigh,NC 27699-1611
70% hth ki
Date Site Visited: 3-Z� -' t
, 13b.Disinfection type: Amount: .,,7J OZ Site Visited By: LI
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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Price:_