GW1--06906_Well Construction - GW1_20241118

t •-WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: . (f)
Y 1.Well Contractor Information: ! 3
CD 3V yy
u,14t.wATE$�VANES`'•r,,„„ "-d;I
WellContractor ame FROM TO DESCRIPTION
'-it- • 172 ft' 15 ft J TO-CR,fPM Oledl
NC Well Contractor Certification Number • 2:3.3?013 :(11S/NG`(foimulfi-a ed:viellss1:OIZT;INF.R:(iLap lies ilex i:i;ti::.. ('
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft in.
Company Name ,;,Zr R:CASSING OR'sTiIRING(gentliiiirui`claia16a) ,: '?.i':; Al v.::: ._ 0
2.Well Construction Permit#: . ". s _ 1 3 FROM TO . DIAMETER naortotess MATERIAL- '
List all applicable well construction permits(i.e.UIC,County,State,Variance,at -4. 1 ft 79 ft. 10 Xi in. ;7 t D Pv�
3.Well Use(check waU use): ft ft In �JA/sG I
Water Supply Well: 0.7XeRAM.;:: T:_ ��:rr=s::"• :� ::;if•�KiFi'i: tc:. _y v:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural ❑Municipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(c1u red) .-.• .,,:: ••:•,.t;,` A•I ;. ---z . : ... .' '2:'
❑Irrigation ❑Wells>100,000 GPD FROM TO IVI4TERIr1L EMPLACEMENT METHOD&AMOUNT '
Non-Water Supply Well: , 0 ft. as ft L 71 9 PS 9 V(+y 1 ii'°J7 s
❑Monitoring :Recovery ft. ft ���
Injection Well: ft. ft.
:Aquifer Recharge :Groundwater Remediation
{r19.SAND/GRAVMPA CW((f►reiica-ble)....__;.....:":`.:. :':'::i3f:'. �r:�`:°w.. -
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ' TO MATERIAL EMPLACEMENTmraloD ' •
DAquifer Test .❑Stonnwater'Drainage - ft ft. • .
:Experimental Technology ❑Subsidence Control ft.. ft
❑Geothermal(Closed Loop) OTracer £20:DRI X GZOG(act c]i sadiliatil Iiiitei'necr3sary)• :•:'> ;•;' ;i:'i'Ors
FROM['Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) TO DESCRIPTION(color,hardness,sail/rock type grain size,etc.)
Date Well Started 10-q-a4 ® ft. Wit ft gal •
4.DateWell(s)Completed: id-9'2 WelIID#f/'•liAQ—a2�-s '19' ft. 302,it Se, _ '`1fi1 * ® grail i'K.
• 5a Well Location: Phone#:33c---iSI-7Va f ft ft t} cJ c1
j'r ik
re i L..,ci f.d 1Y►I°44% ` _ '" _--'
Facility/OwnarName g Facility lD#(ifapplicable) ` NOV .�•
.55'0 Pei ky gsyl clew,Neu aka.j �� �4� ft. ft. �V O 1 %6 2�
•
Physical Address,City,and Zip
'
1✓(�U a��V® t)21rarill'Ah2RC.11.4 eal ...l......': '{ -.,iTY.i Ak .'..'-: .: ..._.. .
County Parcel Idesitif cation No.(PIN) r
l
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
at
6.Is(are)the well(s): ermanent or. ❑Temporary cure of C ed Well Contractor Date
'
By signing this fonn,I hereby certify that the wells)was(were)constructed in accordance with r-
7.Is this a repair to an existing well: ' DYes or ! (a l511NGIC 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.acl explain the nature of the of this record has been provided to the well owner.
repair under#2I remarks section or on the back of this form. 23.Site diagram or additional well details:
8.For GeoprobelDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well constmction 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: f 24.SUBMITTAL INSTRUCTIONS
•
9.Total well depth below land surface: • -3,a. (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdiferent(example-3@200'v @ ')and 2l00
0'
• 10.Static water level below top of casing: /5 (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"+" L�(
11.Borehole diameter: 6 (in,)Bit Off: S/91(J 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
\ Program,1636 MSC,Raleigh,NC,27699-1636
12.Well construction method: r 'lc 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 SUPP``LX WELLS ONLY: • ( 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) l 6 Method of test: \(� Permit Progtam,1611 MSC,Raleigh;NC 27699-1611
'70% hth Date Site Visited: G.-r(j 17 Y cri
-
13b.Disinfection type: Amounts 1 D oz Site Visited By: )I• I
1 y�
Form GW-1 _ North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018 \.
1 I 0,