GW1--06987_Well Construction - GW1_20241119

i
1
•
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: P6
1.Well Contractor Information:
` I gd.e^c '... ./-y Q.4c t ift.c RTC WA'.AVZONES=s-$:E'7 I ,
Well Contractor Name •
FROM TO/�® . DESCRIPTION //�,�
Ot �1�� ft. itos ft- 0 am �3®t A, tOrr.1:°'-�
NC Well Contract or Certification Number IT it 2 /Ovy
:15''OIITER:CASING`(forliiulii•Widffwelrs)`:ORIMPati(ifa"Iicablej.:.:
Yadkin Well Company, Inc. FROM TO DIAMETER MUCHNESS
1 MATERIAL - -_
ft. ft. in.
Company Name `
q ' :•a1"EiII41�R:CASING.ORTQBING:'(geutIeFrali closeiClaop) QJ
2.Well Construction Permit#: l U R IV FROM TO • DIAMETER TRIMNESS MATERIAL '
List all applicable well construction permits(i.e. Cowciy,State,Variance.etc.) 't' ft, l Sti ft Ci Vc hi. SDR" Pvc
3.Well Use(check well use): ft ft. in.
Water Supply W . t11.:I ' ;::; '!':':°::'':?
FROM''.• TO DIAMETER SLOT SIZE • TRIMNESS MATERIAL
❑Agricultural ❑Municipal/Public '
❑Geothermal(Heating/Cooling Supply) esident'tal Watts Supply(ogle) - •
ft. •''�ft in.
❑lndustrial/Commercial. '---' LiResidential Water Supply(shared) y -- ;- ,.
1:..0 .�.;- -'`o .. i i%18.GROUT t'�, '•'• "'; ,;' .
❑Irrigation ,-'••p• ---^ ❑Wells>1100,000 GPD FROM - TO - MATERIAL EMPLACEMENT METHOD trAMODNT
Non:Water Supply Well:.NOV
U q .- 6. ft )3 ft Nvk Pit Pov�J: t 3 he,5 s
❑Monitoring very ft. ':it
•
Injection Well: ;,_:. • .
ft. ft = '
❑Aquifer Recharge 1r.:-.: •. ^'DGroundwaterRemediation - -
❑AquiferStorageandP.ecavery ❑SalinityBamer 1'1SillI ilGRT'V.EI�Ai '(tt ppiica7i)';.'-.:,. .-' '..': :: 'l-', -:;i• .:oy;2-.MATERIAL EMPLACEMENT METHOD .
• ❑Aquifer Test - .;:❑Stamrwatet Drainage • - - it. ft
• ❑Experimental Technology •. . ❑Subsidence Control - ft, ft. .
❑Geothermal(dosed LooP) ' - ❑Tracer • f-20:DRI.ING1OG Wtacli aaditioniIsLeehi ifnecessaryl. .__ ... ..- - • ..'..
FROM TO DESCRIPTION(color,hardness,soll/rodc type,grain size,etc.)
❑Geothermal(Heating/CgolingRctun) .❑Otber(explain wirier#21Remarks).
Date Well Started .IO jiO/0tl: - ��pp ry 0 f' 14? Sey,../ .
4.Date Well(s)Completed: t d1r IO/2Y Weuu m#AH " 14 6' 1 kw 190 - iy .
5a.WellLocation:, - • Phone#:31(9.,r36M.- 0030 I90 f. 1Ss--ft Beak.% uP 420C.ic
W1'!iiu. Lw ld wed►• PIS ft 2.25 it Ce4et 01
Facility/OwnerName . 0- Facility ID#(if applica(ile) 2 S 230 grokg:• oP Kock.
f&q.3 gvo=•ite, kJ �0(..vi.i;i,)JC 23°ft' 301 ft 6rci:tetr
Physical Addrens,City,andZip ,28,p D.` ft. ft
ki
Coutey.T.e ' A - Pamelpicet'irationNo,(PIN), .S
5b.Latitude and longitude in degreeshninntes/seconds or der)ma1 degrees:
r
(if well field,one lamong is sufracient) 22.Certification: Q
v ,,
W
6.IS(are)the well(s): permanent or OTemporary Si a ofCec Sed WellContractor Date
By signing thirfonn,I hereby certify that the well(s)was(were)constructed*:accordance with
7.Is this a repair to an existing well: ❑Yes or j' Io, , ISA NCAC 02C.0100 or ISA NC.0 02C.0200 Well Construction Standards and that a copy
If this is a repay fill out known well construction information mid explabr the nature of the of this record has been provided to the well owner.
repair under#2I remarissection or on the back afthirform 23.5ite 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-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 co f ft
For muhiple wells liar all depths tf different(example-3Q200 and 2Qa 100') ( ) Submit this GW-1 within 30 days of well completion per the following:
-y� 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: J V (ft) Information Processing Unit, MSC,Raleigh,NC 27699-1617
If water level is above casing use"+" 2
11.Borehole diameter: 6._____(m,)Bit Off: G.063 24b.For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: a 6 r /(y 24c.For Water Supply and Open-Loop'Geothermal Return Wells:Copy to the
(ie.auger,rotary,cable,direct push,etc.)
,.. county enviroumrntal health department of the county where installed
i
FOR WATER SUPPLY,WEIZS,ONLY: °'
• 24d.Far Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA Cr
13a.Yield(gpm) _?(1• Method of test: I`(li 4 i Permit Program,1611 MSC,Raleigh,NC 27699-1611
70% llth t U Date Site Visited: AO-6 7
13b.Disinfection type: Amount: i OZ Site Visited By: OV A Ir
DJ
- Pre-Construction: ///,/4 1 ' --F-
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources ' Revised 6-6-2018
Price: