GW1--05116_Well Construction - GW1_20230818

WELL CONSTRUCTION RECORD (GW-11 ,Foi Internal Use Only:
1.Well Contractor Information:
oii @t May t i ,i . ..W1iTE$7AIyF,S`::=:>Well ContractorMimo FROM TO DESCRIPTION
2.571.mA i Lfs 66 -A , . �� ?I t pacacijast &O Rik 1. 7p", i
NC Well Contractor Certification Number "T"ii-W. ... ll' _
:'15."ODTEFC.C'GlSING(formultieasedweils�':ORISNEtZ.Ctf.�a c"t�le),�-- - .
Yadkin Well Company, Inc. FROM To DIAMETER .THICKNESS MATERIAL.
Company Name
.f in.
E.
617DIIt1l:s3ING0&TQBIItIG(1{eritlivmel'cla5hdanoP)___ ___;�:: _. _ /
2.Well Coristraction Permit#: S®9314 G L N d. . FROM TO DIAMETER TRIMNESS .MATERIAL ' y0
Lid all applicable well construction permits(i.e.UIC,County,State,Variance,etc) 4. I ft.
49 i R &e . 1 r'o /,
3.Well Use(check well use): ft. ft. In. Si.,„„
Water Supply Well: FROMs O r DIAMETER« SLOT SIZE TRIMNESS MATERIAL
DAgricultural OMunicipal/Public f
❑Geothermal(Heating/Cooling Supply) ['Residential Water Supply(single) ft. ft. in. Lt
❑Industrial/Commercial _1t .•i�esidential Water Supply(shed) as GROUT v --: - ` -:A�_. - . r - `-
❑Irrigation c E A V!Ii►�7t >100,000 GPD FROM TO MATERIAL EMeLA�>z METHOD rk AMOUNT '�"')
Non-Water Supply e 0 ft. L 2 it Claps 1 O k r
❑Monitoring nu G 1 8 7173 DRecovery ft. ft. -1---
Injection Well: ft
DAquifer Recharge_irbr0 e'aBGc+ ndwaterRemediation ,_ "5.
!ice �� t119.SAND%GRAVEEPA.CKlifiaillnlle) .._...- _-'_ If -_._ B
DAquifer Storage andReclp�er-' ❑Salinity Barrier FROM. ,.TO MATERIAL EMPLACEMEZITMETHOD 3
DAquifer Test ❑StormwaterDrainage _ .
❑Experimental Technology ❑Subsidence Control it. /Pilt: cb
❑Geothermal(Closed Loop) ❑Tracer N2o DR'1 1C}IAG(dttitilfiaditio`nal'sheetiifi eces+iry)1;' _;_,.''..:_.._7.:::_-_: F
FROM TO DESCRIPTION(calo,hardness,salt/rock type,grain size.eta) .
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) y
Date Well Started 14l 7-' c) .3 q 0ft. 1 Z 11"
t �a 7 - .
4.Date Well(s)Completed: 07 -i6"25 Well 1D#AAP - 731 7)ft. no ft. 'd :Scl /'emay A."�.11,0
5a.Well Location: Phone#: )10 iG .�'�j�R, • r/ 4fV f/- / Q
%kV�� 1�r1\d -��e 1� (3�. '/1°141 Gust 18 eft. 2,o (it. �I v . 9 r€_ . _ • s
ft: ftJ$b'Rthrc �"/ 24_
Facility/Owner Name Facility]D#(if applicable) 2 0 7 t 1 � 56 F r�A ��t � YO�.-
707 S. NC 61 /�,�f b fog •}�� 212.it- '30 2. me,�l 1.6,1�' i r e y s
Physical Address,City,and Zip 7 � ft, it.
a 5 - . P
1diIrlei/1 C (s .If
County Parcel Identification No.(PIN) - - - - 0
5b.Latitude and longitude in degrees/minuteslseconds or decimal degrees: - - .
(if well field,one lat/long is sufficient) 22.Certification:
3 6, 0l®'1 j () N `79 , 51cia.09.4 W 1,/r' , 077/E -23�
St;r.*.-1.11�T,.fedW - .:remit • Date
6.Is(are)the well(s): ermanent or ❑Temporary Ru ( l
By sign/this arm hereby certify that the.well(s ere)constructed in accordance with I
7.Is this a repair to an existing well: DYes or )(To 1SANCAC 02C.r 00 or ISA 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. A
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. (�.�-;1
drilled: 24.SUBMITTAL INSTRUCTIONS a{
9.Total well depth below land surface: 36� (ft.), Submit this GW=1 within 30 days of well cempletion•per the fallowi igi
Far multiple wells list all depths ifd(erent(example-3(@200'mid 2(D100) i
10.Static water level below top of casing: 2-0 ( ) 24a: For All Wells: Original form to Division of Water Resources (DWR), (Is
ft Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"/
11.Borehole diameter: {p (in.)BIt Off: __-__- ' ( 24b.For Injection Wells:Copy to DWR,Underground-Injection Control(IUC) •
gg Program,1636 MSC,Raleigh,NC 27699.-1636
12.Well construction method: a I r rt.) 'T(1'J 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
7
FOR WATER SUPPLYWELLS ONLY: 24d.For Water.Wells producing over 100,000 GPD:.Copy to DWR,CCPCUA
� ' Permit Program,1611 MSC,Raleigh;NC 27699-1611
13a.Yield(gpm) t `-/ Method of test: I'/P. g a/'
70%
o hth J Date Site Visited: S�
.
13b.Disinfection type: Amount: �f a,,r) oZ Site Visited By: _
c-
Form GW- North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 6-6-2018 1.71
Price:
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