GW1--06978_Well Construction - GW1_20241118

WELL CONSTRUCTION RECORD(GW-1), For Internal Use Only: CI
1.Well Contractor Information: �'
/`d� a
eem Eta DWI f4't WAtegzoNEsi .:°:'. -, . . . - . . I
WellConpphactorName FROM TO DESCRIPTION
SCd 7g ft. 2 asap ft.. U� 0.
NC Well t Certification Number
Iq o ft ; q i ft— sI q�A, (r�
'.i i OUTER:CNSING`(foc`m firc &:welEYOlt'IDITER741 —ltca2ilef:: .':. _ 3 1
Yadkin Well Company, Inc. FROM_TO DIAMETER _THICKNESS MATERIAL
Company Name
oCo I
I
I 7® q V-6 ;16 DINER;C-ASING-OR TTILlG:(g'l:otliei caT6.16ig la'op)1.:••••
2.Well Construction Permit#: FROM 1 TO . DIAMETER THICKNESS MATERIAL _
List all applicable well constnteflon permits(i.e.UIC,County,State,Variance,Oa) + I ft , 6 3 ft . 4/7, m / p u •
3.Well Use(check well use): ft ft
in aSZ)�Lit- 36
7 CRIE&
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft/ ft in.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) y ®
❑Industrial/Commercial DResidential Water Supply(shared) "// """ �� "" .
•❑Irrigation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ® ft. J i ft ! '3 ¢®..4 e ii 6,4,, ��
DMonitoring DRecovery ft ft w
Injection Well: • ft ft
❑Aquifer Recharge ❑GroundwaterRemediation
I LS S GRVaTA if ppixe1Jle):::i r`- :_:`:
❑A RecoveryuiferStoraoeand ❑Salm Basler •
PROM TO MATERIAL EMPLACEMENT METHOD •
❑Aquifer Test ❑Stormwater Drainage ft. ,..."' i.�"'
❑Experimental Technology 0 Subsidence Control'
❑Geothermal(Closed Loop) . ❑'tracer '•RO:'DRI1.,77NGIGOG(dtticli"ailditionarsheets'if.'riece"ssary)":'::'<":;s:°;,`.
❑Geotht rural(Heating/Cooling Return) 0Other FROM TO DESCRIPTION(color,hardness,soWrock type,Brain sve,etc.)
(H g/ (explain under#21 Remarks)
Date Well Started / -A i 44 0 ft �-,� ft ja
4.Date Well(s)Completed: III-2)s 2 Y Well ID#1# " 3 72- A�,�ft. I/0 ft sw i 6 pa n s ;t . ,
•
5a Well Location: Phone#:70 ti— 6 77-W07110 ft. 34)z ft (' /// i
f. ft.
rant► 4" fild i3.111,.. St4,tnia.S
Facil ty/OwnerN1 ame Facility DD##(if applicable) ft ft . ,
gLrl16r f I .tQj •1 T�fail W-3ltlfC.ttlsoA1 4i6614 ft ft '�J
Physical
AddrTh,City,and Zip ft ft WO . i+ L U L`!
County Parcel ld-ntificationNo.(PIN) yt : ,
51.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
3( , 32944 N 8I , 1133 17
6.Is(are)the well(s):)Permanent or ❑Temporary Si azure of Certified Well Contractor Date
By signing this form,'hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or �1Vo ISA NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and✓explain the nature of the of this record has been provided to the well owner.
repair under#21 remarla 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
constmi:tion,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: d (ft
For multiple wells list all depths ifdi$erent(example-3Q200'and 2Q100) ) Submit this G W-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 6 0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+" Infotmation Processing Unit,1617 MSC,Raleigh,NC 27699-1617
/� 3 s1 24b.For Injection to D
11.SorehoIe diameter: 1� (in.)gi f O f f: 3 ,r 1 Copy WR,Underground Injection Control(WC) 0
Program,1636 MSC,Raleigh,NC 27699-1636 .
12.Well construction method: a ! /(3 A�+y
(i.e.auger,rotary,cable,direct push,etc.) 24c.For Water Supplyand Open-Loop Geothermal Return Wells:Copy to the 14.53county environmental health department of the county where installed 1
SU
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA --F-
t Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) SO Method of test: I" CI I
70% hth �Y% �' Date Site Visited: 3-4.- IN /®-fie(
13b.Disinfection type: Amount: OZ Site Visited By: ,,t j
irk' — co i 3+ 1
FormGW-1 North Carolina Department of Environmental ire,
-Division of Water Resources Revised 6-6-2018
Price: