GW1--06971_Well Construction - GW1_20241118

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: n
Hki ` 4t•V1A3 ZONES'•• ;es.'rs.:. I'..,'.; • _. , . . •
FROM TO DESCRIPTION
Well Contractor Name
���IJ t IOC/ ft. I IS ft 1IS(:� "- / !d �j?/°1 Iv.
200 ft a2cift I er •e.. 444.6,01, I3
NC Well Contractor Certification Number I15'OUP:CASING'(for>multi;casedValLis:OR'IINFR,(iLs 11 5
c"ha 14T..;:: .•
Yadkin Well Company, Inc, FROM TO DIAMETER T ICRNESS �j MATE
ft. ft in, .`
Company Name ;,16fII`II3EIY:CASING.ORM.'SING(efitIie malelo'sed'looPT::.•r�::`>•••� :::r: •:: . 03
2.Well Construction Permit#: t IS. 7 L 3 FROM TO _ DIAMETER THICKNESS MATERIAL
List all applicable well corisiructionpermits(i.e.IBC County,State,Variance,etc) i I ft, .5 'ft-/ tII rn. ( (/ 7 i y�/
• 3.Well Use(check well use): rili;STai ft ft. (� I in.
)rj L w.�
Water Supply Well: • ROM > o: :'..�.`,D> _ ::g',:sLT--... '.-_ ` .:-TRICKNE, T.
❑Agricultural ❑Municipal/Public ft in. 7"❑Geothermal(Heating/Cooling Supply) Ft esidential Water Supply(single) ft ft. b. .
❑lndustrial/Commercial . ' . ❑Residential Water Supply(shared) :Ig;ToRODTt::::;':.:5.:-;- : ' • . •..-.. = . - -- • -.
❑Irrigation . ❑Wells>100,000 GPD FROM TO MATERIAL. EMPLACEMENTML+TEOD&AMOUNT
Non-Water Supply Well: •r ft. 20 ft 15 CK 1p t9 av( -rB/12 h'z-s
❑Monitoring ❑Recovery ft ft /r
Injection Well: ft, ft.
❑Aquifer Recharge .❑Groundwater Remedia1im
%I9.SA D/GI2 A I3YAiGl'( pPlicc'ali1a)" .. I .
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MA EMPLA METHOD • •
❑Aquifer Test ❑Stormwater Drainage ft ft.
❑Experimental Technology ❑Subsidence Control ft.. ft. ( _
❑Geothermal(Closed Loop) ❑Tracer '20:DRIf NG-TAG(sttach additiiiiii sheets itne'drssary):.- •.-
❑Geothermal(Hearin Cooling etum) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(mIar,hardness,saNrock type grain size,eta)
Date Well Startedl --:Z d�/� erg�r 0 f ft --$.c`"
4.Date Well(s)Completed:• �� 'Z l Well ID#/ P�"e la- 3 3 7 7 1. fr' 7,,6 ft k 00,-
5a.Well Location: Phdile#: 10 7-fin -5.2g 14 ft 1 O ft. 1h �-rot IL /I. r�Ji. 9P-7- -
Q J 00 ft. [ 15 ft' 'Pin►�f e k she i9-
N`�' cl'i I, p,rt>�s:�b�t• ®� Ad.60k/us d
Facility/OwnerName Facility 1D# if applicable) 15 ft 1400 ft VI 44 ill(
3Vl) . 1 . gae1 Ped441 IR ficlOti L-lIua. ft 582ft et nve G
Physical AddrestrCity,and Zip V0104 ft ft.
An-
Av I ty, 5.4%LA N Qa ,:,,.'s.... ', -• -
County Pt el Identification No.(PIN) G.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Nevi Cl 4'
(if well field,one lit/long is sufficient) 22.Certification: Q
• -7-,t , - . -- ..' ..-,-,... t...:q 63,5,
)(-11-A-11•4X-911-N.,,111-f-W76.1--w --7.T;;;,,d0_2_L'i---,:-..„,:,...-.., - ,.....
di
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ermanent or DTemporary •
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: ❑Yes or Io 15A NCr1C 02C.0100 or ISA NCAC 0.2C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information atlfl explain the nature of the of th record has been provided to the well owner.
repair under#21 remarls 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: ) U (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3(g200'and 2Q100)
( 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: CO ft') Information)'rocessing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level Ia above casing use„+^
11.Borehole diameter: ' (in.)Bit Off; 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IOU)
�' D program,1636 MSC,Raleigh,NC 27699 1636
12.Well construction l method: tfi/.� / 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
FOB. •
WATER SUPPLY WELLS ONLX:Method24d.For Water Wells producing over 100,000 GPI): Copy to DWR,CCPCUA t
13a.Yield(gpm) 2 3Y Permit Program,1611 MSC,Raleigh,NC 7699-1611
of test: eit A i f I�
70% hth Date Site Visited: t2 a d2 d -7/n
/ oZ
. 13b.Disinfection type: Amount: I ! Site Visited By: 6 it
-
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revissyd 6�=2018_%--
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