GW1--06969_Well Construction - GW1_20241119

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WELL CONSTRUCTION RECORD(GW 1I For Internal Use Only:
1.Well Contractor Information:/ "" '
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FROM TO DESCRIPTION clt
Well Contractor Name • ft. 1,49 ft 3 8' 1 6 "�
Nryryl�S?i4 •
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NC Well Contractor Certification Number ' v- e^v-
;15.'OUTER:(?AS1N,G.(formultixcase3;iieIIsjORIiTCTEHAiap`licalilefs`:"��:._ . _ :�
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft in.
Company Name
P Y F.03.11INkIt:C:9SIDiG2012s1 u2iING(geatliei mal''clos'ed loop):'.:sS?;� „ ;.,;, X•_:: o•
2.Well Construction Permit it: FROM TO . DIAMETER , THICKNESS MATERIAL
List all applicable well construction permits(. minty,State,Variance,etc) .4 r ft. " 4 ft G r6 f in. spQo` Pvc
3.Well Use(check well use): .ft ft in.
LJ2• CIanr- �r.i.''' IuL ::;1'+ai „l �liiI bt ti« .:a...._.:.:c.._> ~.._: �vP:• .ys•; '
Water Supply Well: . FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL'
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft in.
• ❑Industrial/Commercial ❑Residential Water Supply(shared) 1,18::GITdUT':7: :_;.;;-r. 7:•ww70=a-:;'.:• ;'---,.S; ::'-..-:3•----..:qua:u>ri
nigation ❑Wells>100,000 GPD FROM TO MATERIAL HM LACENIENTMETHOD&AMOUNT
. Non--Water Supply Well: , _--;-t ' 0 ft' 23 Hole pru6 f ueee) Q �95
❑Monitoring 4.- ^°, F .' 'OR ft 1-1ecovery ft ft. �! •
Injection Well: C Z(� • ft. ft
['Aquifer Recharge ��Qv 1 ei LO .❑GroundwaterRemediation
. I19::S D/GR4VETIY;ACT (iO1pp1ihhIe):' '_i%:-k^.`v , s:;'..5.<i•,: ear-_:,c;
❑Aquifer Storage and Recovery _,.-;,••,;'['Salinity Barrier FROM TO MATERIAL EIYIPLACEMENTMETHOD •
❑Aquifer Test \r`�. ' 'i �) ❑Stornwater Drainage ft ft -
❑Experimental Technology ❑Subsidence Control ft, ft
❑Geothermal(Closed Loop) ❑Tracer 'e20?DRII,T.'INGI;OG(atfac'ti`ifiditi`o"naI'slieetifidnec is iFy)°i,•l;-._ ,1€�'
' FROM - I TO I DESCRIPTION(color,hardness,son/rock type,grain size,eta)
❑Geothermal(Eleating/Cooling Return). ❑Other(explain under#21 Remarks) <
Date Well Started 10t ® tog ft ' "„e
4.Date Well(s)Completed: I C�l ay Well ID A L a/ g 1,9 ft. 1i ft . GC,teti!Y
. -777�-g217 -a ft t
Sa.Well Location: �. � � $(i f �f o�g�•.,Qoe1C • --S
Phone#:
nic X4.0,1 I i Act-sew 8‘ Zoa ft Pr ., roil
Facility/OwnerName • Fan tityID#(if applicable) .. -
/roq SA e-r wood Cofe.c4' .1)r �' �'1b r3�'�ri3 ft ft. .
Physical Address,City,and Zip a fe4 'eGIi ft. ft
°1 BB S i G d2I*i2F.MA17(S . .. ti`.: iZ'::-ra ;:'au:; -- 7•"
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County Parcel IdenfificatienNo.(PIN) s� /t i(P �41 •
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) G 22.Certification:
36 ° , I . 3.2''N ,O f tD . g ' /3 �� W 101 d I
• ct '
6.Is(are)the well(s): Permanent or ['Temporary Sig of C ' d Well Contractor 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 Ao 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out]mown well construction information and explain 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 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: 0 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths tfdWerent(example-3Qa 200'and 2Q100)
10.Static water level below topof casing: S.0 (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.BorehoIe diameter: 6 'in.))3it Qf f; �> 1 24b.For Injection Wells:Copy to DWR,Underground Injection Control(ACC)
Program,1636 MSC,Raleigh,NC 27699-1636
• 12.Well construction method: eil A I CO�Gl r 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 GPD: Copy to DWR,CCPCUA
' Permit Program, MSC,Raleigh)NC 27699-1611 03
13a.Yield(gpm) 30 Method of test: f i t o
o Date Site Visited: A /Ji 2 (f
. 13b.Disinfection type: 70/o hth Amount: 1 OZ Site Visit d By: iii 46,I
/LedL `J4
Form GW-1 North Carolina Department of Environmental Quality-D rsionof Water Resources I , Revised 6-6-2018
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