GW1--06974_Well Construction - GW1_20241118

WELL CONSTRUCTION RECORD(GW-1) Pei internal Use Only:
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1.Well Contractor Information:
4[ ''111S Ilifi,1 ±' a:WA1SR'ZONES . 4:_. f�
'PROM TO DESCRIPTION
Well Contractor Name ft. r2,P.: ftto®i..Q� _ e�1
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- "'1 f105 : fc -B R ft J `a
NC Well Conlxaetar Certification Number
`.15 Ob. i:6;9SING'(cremate-eusod:Oiefs)`:ORflNBRi(i£a"•llcalile): i-::
Yadkin Well Company, Inc. FROM- TO -_-- DIAMETER TRIMNESS 1 MMT'tEXAL
• ft.l rt. in.
Company Name „.:
i ;i163NNER:CASING:ORSQBINGareitL`eimalcinsernO ... ,•
2.Well Construction Permit#: II �J � FROM TO . •DUMMER THICKNESS _•MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 1 it too•
ft. 1 Y4 1D"_SJJ@.a l Pu c- _
1 fL ft' - to
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3.Well Use(check well use):
Water Supply Well: ;i FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgriculfuaal ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. fL in.
❑]ndustriai/Commeruial . �-❑Residential Water Supply(shared) ;aei'GBo n - ;. :": '; '
Ob igation DWells>100,000 GPD FROM TO! (MMATERIA/L EMPIAOKME,NT METHOD&AMOUN'
Non-Water Supply Well: /❑Recovery 6 ft a! n ' "(11e. Plug Pout.& 12-
❑Manitmiug
InjectiotiWell: 1, ' fr. ft.
DAquiferRecharge ❑Groundwater Remediatirm !'19,SAND1ilgit RACIi�Crfap'ph"ttle) ; . : - ... - ....•...:,
ra
❑AquiferStosage and Recovery • '❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD ' •
DAquiferTest;. • t StormwaterDrainage ft. ft.' °Experimental Technology ddd❑Subsidence Control ft-. ft. •
IOGeottiermal,(Closed Loop) ❑Tracer 20:Irn3LLI$G1OG(attach iadit heel sheeti if necessary).
❑Geodpurnal-(Heating/CoolingRetain) ❑Otiier(explain under#21Remadcs) FROM TO DESCRIPTION(eater,hardnensatl/raektype,gnin�eems)
Date Wet!Started Itt. ft-Coio-414 0 Sc. /
4.Date Wells)Completed i I-('�" p j�Well ID#��43� 4 I 4 40 it. s 0 n ItIv1Ck Skzete-
Sad.WellLacation: Phone#:33 6- 11 i(, "jr-t i Lir 50 ft: 1 a 0 ft: eqal41(len
ac Q lO P�7 A e, 1si0 fL 100 ft' !-1 1n 6 e. -
FaciliiylthvaerName Facility II?#(if applicable)
Physical Addiess,City,and Tap Crft. it ,' a..
(�C64127 C a, /NC.::2.� r�aK,,: . .,.-, ts'l
County `, ParcelIdrnt:firationNo.(PIN) }
Sb.Latitede and longitude in degreeshninntes/seconds or decimal degrees: tE . :'.-
(if,well field,one latllong is sufficient) 22.C., ..cation: , (,:';`u',,;;.�(-:;:) 0)
3663 .s8JSgi1 N gib' , 7 ' /1l/ - rr
1 1- ta-,;;-1/4i r
' 6.Is(are)the well(s): ermanent or ❑Temporary S'„ .�of Certified Well Contractor ®--.66,„.Ja .49 0 5.....a_ Date
By signing this fonn,I hereby certrfy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 'No ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out brawn 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 an the back ofthis 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 Over'in Remarks Box).You may also attach additional pages if necessary.
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drilled:- A 24.SUBMITTAL INSTRUCTIONS
9.Totalwel depth below land surface: 3 4 at'
(it) Submit this GW-1 within 30 days of well completion per the followiagi
For:multiple wells list all depths(1d(fferent(example-3@200'and 2(100�
[AO
A O s (R 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level e below top of casing: t x ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing USG"+"
11.Borehole diameter:- _____..C111.)Bit Off: 5 a '1 i0 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Cis 9 fcy i/n.r y 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the 1 '
(i.e.auger,rotary,eabk,direetpush,etc.)
- county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLX:, • I '
24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA -
13a.Yield(gpm) �0"1' 'Method of test: ,p'a A,/,' Peimit Program,I611 MSC,Raleigh,NC 27699-1611
70%E th Date Site Visited: W 2 3 ViS /0 -17 2 V•114§
13b.Disinfection type: Amount: 13 OZ Site Visited By: I
Pre-Construction: Al.,
2
Form GW-1 North Caroline Department of Environmental Quality-Division of Water Resources ' Revised 6-6-2018 -•
Price: _ ! : '
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