GW1--06889_Well Construction - GW1_20241118

WELL CONSTRUCTION RECORD (GW-1' For Internal Use Only: I
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1.Well Contractor Information:
lliel WI(C,‘i:X Wi.d wazi'zoriEsV.:':::'. ! t
FROM TO ,•' DESCRIPTION
Well ContractorNAne � • if7ft ill it
13i ' .' P.
O' 7 qt" ft ft.
NC Well Contractor Certification Number
Yadkin Well Company, Inc. a; `'n :04-S1N9`(form;illire ea; e>s :Oz nv ;ci: liFalil'A;;&V: :
FROM TO DIAMETER THICKNESS MATERIAL
ft it in. •1V9•
Company Name
04
a -•a`,T6.`•'JlR`IER1G-ASING'ORs1 U.BILWgT tlietmal clos'enbrp ,:;-.:-4...‘,...:-..;.... .
2.Well Constr
uction Permit#: 4/01 i 0 8' FROM TO . DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 4, ( ft gee �+ft .. e�� n o 6,/8` A-Iv r
iD
• 3.Well Use(check well use): ft ft in. ® �
Water Supply Well: ,VS- ..._ ..7',r: ,'. ";::� ::2:." 121:r.,�� :..�. .'�
i FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft, ft in-
❑Geothermal(Heating/Cooling Supply) Xesidential Water Supply(single) ft ft. in.
❑Indushial/Commercial -❑Residential Water Supply(shared) 18'`;GROUT;; '=1-� , , "r'.. .'.- .,.'r' " ,;,
❑Irrigation t dWells>100,000 GPD FROM TO 1MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q ft. 3 e ft rti-eA.� pd j r�
❑Monitoring pRecpvery ft. ° ft
Injection Well: , • rif t 3 d ���8'a��� 3! eve'
ft. ft. d
DAquifer Recharge ❑Groundwater Remediation _-_
+ 119::SANDIGR2IV.PT;:1'AGK(za'gili alilej:;;r" ..r7,ZID'i ,.+5.}-:Y•-"_' '..r.. :.
❑Aquifer Storage and Recovery ' Salinity Barrier FROM TO • MATERIAL EMPLACEMENT METHOD: - • •
❑Aquifer Test 11Stomrwater Drainage ft ft
❑Experimental Technology I:Subsidence Coritral ft ft.
❑Geothermal(ClosedLoop) ❑Tracer 11 '•'r2DrD INGI:OG(ittinCiddiliiiiil:slieeti f:iiiiisiafy) - - _.r�"<� ,..
❑Geothermal(Close g/Coolin'Retum) ❑Tracer Other explainunderMIRemars) FROM TO '?ft.
DESCRIPTION(color,hardness,salllrocktype grain size,etc.)
Date Well Started / A t-40.34, ® ft -SDr
4.Date Well(s)Completed:/,/-`G- eF 6 f Well113:t 4 -' (3 i $7 ft. �®n3t ft f e' t J n'te
5ar.Well Location:
phone_#: /07' 4/o�' ift3 ft. ft II �J am/Ile -
...).---i/r1 4c4 Pe l�rj E .• ft. ft. -•.. -_., , '..', r-
Facility/Oamer Name a� Facility ID#(if applicable)
L0- I 124 S1...�1, W . Plea-�--woo J.'Me, ft. ft NOV 1 b Z024 •
Physical Address,City,and Zip e2®t.Z L9 ft' ft. r •„ -_ --; ,'' -'';,' `_ ,':.
cA 4 1"2l1331,lalt.TCS. 4..�. •r ...�._. . l�,Fi4;, er::sj: u.. . ._--r ��,�
County 4. * Parcel Identification No.(PIN) •
`�S3
5b.Latitude and longitede in degrees/minutes/seconds or derimal degrees:
(if well field,one lat/long is sufficient) 22.Certificatioii:. ,
• 3 �' �'° N S.�a 30 7/I W (y .
6.Is(are)the well(s): ermanent •or ❑Temporary' sign of Cettifie ell Contractor 11-4.441Y k'
Date
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 o ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and lain 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 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 GV 1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
chilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface': f�t� '3 • (ft) Submit this GW-1 within 30 days of well completion per the following'
, For multiple wells hit all depths if different(example-3©200d and 2@100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: �� (ft) Information Processing Unit 1617 MSC,Raleigh,NC 27699-1617
If water level is above casing use"+"/
11.BorehoIe diameter: W Cm.)Bit Off: 4 130 24b.For Injection'Wells:Copy to DWR,Underground Injection Control(IUC)
t Program,1636 MSC,Raleigh,NC 27699-1636 `•
12.Well construction method: A r Po.�'ex•7 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the \
(ie.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 GPD:Copy to DWR,CCPCUA
' Permit Program,1611 MSC,Raleigh,NC 27699-1611 ��
13a.Yield(gpm) /`4r Method of test: Ci C /f
o j-4 Date Site Visited: 4 ' /9—2',`/
13b.Disinfection type: _�° hth Amount: Ile'' OZ Site Visited By: 0410 l
i
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
Prim- .