GW1--06901_Well Construction - GW1_20241118

13,, 1; ,CONSTRUCTION RECORD(GW-11 For Internal Use Only:
f i1.1,411 Contractor Infor lion• n
t e / �
14z WA714ZONES'lrM'ax �': t'•'
,�;Well`.'ontraetor ame FROM TO DESCRIPTION / r�+�
Ir A fL I' ft S6� tY , G c
/�/ � ft r it �" l C`'•• NC W,eIIContractorCertificationNumber 1.5.`'ODTER,cLTSING`(fo%`mniti;c"ssef�weII]OR7;1PILrR•:Gf 1ica er
'' �,Yadk'in Well Company, Inc. FROM TO DIAMETER Win:EMUS MATERIAL '
a /' ft. ft 1 in.
CompanyNamo lra�}t�`Y�f�� 3 3C-CO/' 76 axer.AVP.R:ossiwG_ORuI3ING;okiiecmaratikaloo7`•-. .. ._. .
2.Well Construction Permit#: 2.ii'— 0 7.. Lowy/4 P—0 04 g-3 FROM TO• DIAMETER s_. Q �i RrAL ..-
List all applicable well construction permits(he.UIC,Cowry,State,Variance,etc.) i ft ft �j m'•; I �r/�`p�;
ft. ft V� in.
3.Well Use(check well use): .
•
Water Supply Well: i~:17 CisF r�:`F ;, =.' :<`::zi•-f: — --
FROM TO •DIAMETER ,SLOT SDM TBICIMESS y MATERIAL
• ['Agricultural.. 'OMunicipa1Public ft. ft in. .
'❑Geothermal(Heating/Cooling Supply) (esidential Water Supply(single) ft ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(Shared) x.- ;-n,,f.,,=::aj.. --
IB:,GRODT,:: ..�, ! ��>C: �: � Y =iti: lvw
❑irrigation OWells>100,000 GPD FROM TO _MATERIAL CEMEIorr METHOD&AMO
Non-Water Supply Well: ft. ft. ��}�
,• ❑Monitoring ❑Recovery tO' ft • ft b�� iv. .g
Injection Well: ft • ft.
. DAquifer Recharge •❑GroundwaterRemediation '' •
DAquifer Storage and Recovery ❑Salinity Barrier t"19:SANDAIEei;'VFra3'a� (it ATER'c"a"li7ejs't...-..,. '•:',.:•:`..r:"0.:.`.u°:.
FROM TO MATERIAL CEMENT METHOD
:' oAquifer Test • ❑Stormwater Drainage ft. .ft
['Experimental Technology OSubsidence Control ft, ft
•
❑Geothermal(Closed Loop) ❑Tracer •201D101f 1NGZOG'ittiich idillhonsirilieef'ifnecess
FROM TO . ' DESCRIPTION(color,hardness,sollErock type,grain sire,"eta) -
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft ft � Je( - ... .. -
Date Well Started : p � `�d
4.Date Well(s)Completed: Q-1• —a Well m#
k
Sa.Well Location: Phone#:S&m V•7-'Q�1 �� t 'it ��� 'Pr c`
c ' vt 'W�1
• Facilittyp/O,tvnarName��®® ry Facility I(D#�(if applicable)
• :.),•,:PhysicalAddress,City,and Zap 2 J2j9' ) ; ft f.
ai.P01,4 .2L:ZtF.MA'RKC;`,i _ i. • g.:101 i. i i_411ti.: 4 .•;-;::.:s ; z:
Couut'• Parcel Identification No.(TIN) .
• Sb.La"ti d'tude and longitude degrees/minutes/seconds or decimal degrees: -'" '
(ifivellfie;d,onelat/longissufficient) 22.Certificati .
� ��`� N •
7 f , Re�z1 W v ' `iQ�f
�_® gnature eitiSed Well Contractor ' . Date
6.Is(are)tha well(s): �ermar-ent or ❑Temporary .
lly signing this form,I hereby certify that the well(s)was(here)constricted in accordance with
,. 7.Is this a repair to an existing well: DYes or L'fo ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this iss a repair,fill out known well construction it formation and explain the nature of the of this record has been provided to Ate well owner. ?•
repair under#21 remarls section or on the back ofthisform.
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 GW 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: 5101.
(ft) Submit this GW 1 within 30 days of well completion per the followings
Far multiple wells list all depths fdWerent(example-3Q200'and 2Q100) ,
24a. For All Wells: Original form to Division of Water Resources (DWR), •
10.Static water level below top of casing: SO -al) Information Processing Unit,1.617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: (in.)Bit Off. S• 24b.For Injection'Wells:Copy;to DWR,Underground Injection Control(IUC) 0V Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: , I.I, I o 4 fry 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the , `.,p'
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed -,;a.....„
�
FOR WATER SUPPLY WILLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA w i�
(gpm)
r 1 V Permit Program, MSC,Raleigh,NC 27699-1611 �'�
13a.Yield • Method of test: i' '
•70% hth '• ' • oz Date Site Visited: 7'24 isz 9
' a
ar
. 13b.Disinfection type: ., Amount: • Site Visited Sy: A9 ei 41 ®e;v.i
® 1•
NForm GW-1.1', North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018